20192 - Microsoft · H0423_MEM19_2112v2_C Non-Marketing 08132018 OMB Approval 0938-1051 . 2019 Evidence of Coverage for MetroPlus Advantage Plan ... Social Security, Medicaid (the

20192 019

January 1 – December 31, 2019

Evidence of Coverage:

Your Medicare Health Benefits and Services and Prescription Drug Coverage

as a Member of MetroPlus Advantage Plan (HMO SNP)

This booklet gives you the details about your Medicare and Medicaid health care and

prescription drug coverage from January 1 – December 31, 2019. It explains how to get coverage

for the health care services and prescription drugs you need. This is an important legal

document. Please keep it in a safe place.

This plan, MetroPlus Advantage Plan (HMO SNP), is offered by MetroPlus Health Plan (When

this Evidence of Coverage says “we,” “us,” or “our,” it means MetroPlus Health Plan. When it

says “plan” or “our plan,” it means MetroPlus Advantage Plan (HMO SNP).)

MetroPlus Health Plan is an HMO plan with a Medicare contract. Enrollment in MetroPlus

Health Plan depends on contract renewal.

MetroPlus Health Plan is an HMO plan with a Medicaid Managed Care contract. Enrollment in

MetroPlus is dependent on meeting all eligibility criteria.

This document is available for free in Spanish and Chinese.

Please contact our Member Services number at 1-800-986-0356 for additional information. (TTY

users should call 711.) Hours are 24 hours a day, 7 days a week.

ATENCIÓN: si habla español, cuenta con servicios de asistencia lingüística sin cargo

disponibles para usted. Llame al 1-866-986-0356 (TTY: 711).

注意：如果您說中文，可以免費獲得語言協助服務。請致電1-866-986-0356（聽力障礙電

傳：711）。

We can also give you this information in Braille, large print, or other alternate formats upon

request.

Benefits, premium, deductible, and/or copayments/coinsurance may change on January 1, 2020.

The formulary, pharmacy network, and/or provider network may change at any time. You will

receive notice when necessary.

H0423_MEM19_2112v2_C Non-Marketing 08132018

OMB Approval 0938-1051

2 2019 Evidence of Coverage for MetroPlus Advantage Plan (HMO SNP)

Table of Contents

2019 Evidence of Coverage

Table of Contents

This list of chapters and page numbers is your starting point. For more help in finding

information you need, go to the first page of a chapter. You will find a detailed list of topics at

the beginning of each chapter.

Chapter 1. Getting started as a member .................................................................. 5

Explains what it means to be in a Medicare health plan and how to use this

booklet. Tells about materials we will send you, your plan premium, your

plan membership card, and keeping your membership record up to date.

Chapter 2. Important phone numbers and resources ........................................... 20

Tells you how to get in touch with our plan (MetroPlus Advantage Plan

(HMO SNP)) and with other organizations including Medicare, the State

Health Insurance Assistance Program (SHIP), the Quality Improvement

Organization, Social Security, Medicaid (the state health insurance program

for people with low incomes), programs that help people pay for their

prescription drugs, and the Railroad Retirement Board.

Chapter 3. Using the plan’s coverage for your medical services ........................ 40

Explains important things you need to know about getting your medical care

as a member of our plan. Topics include using the providers in the plan’s

network and how to get care when you have an emergency.

Chapter 4. Benefits Chart (what is covered and what you pay) ........................... 55

Gives the details about which types of medical care are covered and not

covered for you as a member of our plan. Explains how much you will pay

as your share of the cost for your covered medical care.

Chapter 5. Using the plan’s coverage for your Part D prescription drugs ........ 104

Explains rules you need to follow when you get your Part D drugs. Tells

how to use the plan’s List of Covered Drugs (Formulary) to find out which

drugs are covered. Tells which kinds of drugs are not covered. Explains

several kinds of restrictions that apply to coverage for certain drugs.

Explains where to get your prescriptions filled. Tells about the plan’s

programs for drug safety and managing medications.

Chapter 6. What you pay for your Part D prescription drugs............................. 126

Tells about the four stages of drug coverage (Deductible Stage, Initial

Coverage Stage, Catastrophic Coverage Stage) and how these stages affect

what you pay for your drugs. Explains the two cost-sharing tiers for your


Table of Contents

Part D drugs and tells what you must pay for a drug in each cost-sharing

tier.

Chapter 7. Asking us to pay our share of a bill you have received for covered medical services or drugs.................................................... 143

Explains when and how to send a bill to us when you want to ask us to pay

you back for our share of the cost for your covered services or drugs.

Chapter 8. Your rights and responsibilities ............................................................ 150

Explains the rights and responsibilities you have as a member of our plan.

Tells what you can do if you think your rights are not being respected.

Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) ....................................... 162

Tells you step-by-step what to do if you are having problems or concerns as a

member of our plan.

• Explains how to ask for coverage decisions and make appeals if you are

having trouble getting the medical care or prescription drugs you think

are covered by our plan. This includes asking us to make exceptions to

the rules or extra restrictions on your coverage for prescription drugs, and

asking us to keep covering hospital care and certain types of medical

services if you think your coverage is ending too soon.

• Explains how to make complaints about quality of care, waiting times,

customer service, and other concerns.

Chapter 10. Ending your membership in the plan.................................................. 219

Explains when and how you can end your membership in the plan. Explains

situations in which our plan is required to end your membership.

Chapter 11. Legal notices......................................................................................... 229

Includes notices about governing law and about nondiscrimination.

Chapter 12. Definitions of important words............................................................ 243

Explains key terms used in this booklet.

CHAPTER 1

Getting started as a member


Chapter 1. Getting started as a member


SECTION 1 Introduction ........................................................................................ 6

Section 1.1 You are enrolled in MetroPlus Advantage Plan (HMO SNP), which is a

specialized Medicare Advantage Plan (Special Needs Plan) .......................... 6

Section 1.2 What is the Evidence of Coverage booklet about?.......................................... 7

Section 1.3 Legal information about the Evidence of Coverage........................................ 7

SECTION 2 What makes you eligible to be a plan member? .............................. 8

Section 2.1 Your eligibility requirements .......................................................................... 8

Section 2.2 What are Medicare Part A and Medicare Part B? ........................................... 8

Section 2.3 What is Medicaid?........................................................................................... 9

Section 2.4 Here is the plan service area for MetroPlus Advantage Plan (HMO SNP)..... 9

Section 2.5 U.S. Citizen or Lawful Presence ..................................................................... 9

SECTION 3 What other materials will you get from us? ................................... 10

Section 3.1 Your plan membership card – Use it to get all covered care and

prescription drugs .......................................................................................... 10

Section 3.2 The Provider/Pharmacy Directory: Your guide to all providers in the

plan’s network ............................................................................................... 10

Section 3.3 The plan’s List of Covered Drugs (Formulary)............................................. 12

Section 3.4 The Part D Explanation of Benefits (the “Part D EOB”): Reports with a summary of payments made for your Part D prescription drugs .................. 12

SECTION 4 Your monthly premium for MetroPlus Advantage Plan (HMO SNP)................................................................................................... 12

Section 4.1 How much is your plan premium? ................................................................ 12

Section 4.2 There are several ways you can pay your plan premium .............................. 14

Section 4.3 Can we change your monthly plan premium during the year?...................... 15

SECTION 5 Please keep your plan membership record up to date ................. 15

Section 5.1 How to help make sure that we have accurate information about you.......... 15

SECTION 6 We protect the privacy of your personal health information........ 17

Section 6.1 We make sure that your health information is protected............................... 17

SECTION 7 How other insurance works with our plan ..................................... 17

Section 7.1 Which plan pays first when you have other insurance? ................................ 17



SECTION 1 Introduction

Section 1.1 You are enrolled in MetroPlus Advantage Plan (HMO SNP), which is a specialized Medicare Advantage Plan (Special Needs Plan)

You are covered by both Medicare and Medicaid:

• Medicare is the Federal health insurance program for people 65 years of age or older,

some people under age 65 with certain disabilities, and people with end-stage renal

disease (kidney failure).

• Medicaid is a joint Federal and state government program that helps with medical costs

for certain people with limited incomes and resources. Medicaid coverage varies

depending on the state and the type of Medicaid you have. Some people with Medicaid

get help paying for their Medicare premiums and other costs. Other people also get

coverage for additional services and drugs that are not covered by Medicare.

You have chosen to get your Medicare health care and your prescription drug coverage through

our plan, MetroPlus Advantage Plan (HMO SNP).

There are different types of Medicare health plans. MetroPlus Advantage Plan (HMO SNP) is a

specialized Medicare Advantage Plan (a Medicare “Special Needs Plan”), which means its

benefits are designed for people with special health care needs. MetroPlus Advantage Plan

(HMO SNP) is designed specifically for people who have Medicare and who are also entitled to

assistance from Medicaid.

Coverage under this Plan qualifies as Qualifying Health Coverage (QHC) and satisfies the

Patient Protection and Affordable Care Act’s (ACA) individual shared responsibility

requirement. Please visit the Internal Revenue Service (IRS) website at:

https://www.irs.gov/Affordable-Care-Act/Individuals-and-Families for more information.

Because you get assistance from Medicaid with your Medicare Part A and B cost-sharing

(deductibles, copayments, and coinsurance) you may pay nothing for your Medicare health care

services. Medicaid may also provide other benefits to you by covering health care services that

are not usually covered under Medicare You may also receive “Extra Help” from Medicare to

pay for the costs of your Medicare prescription drugs. MetroPlus Advantage Plan (HMO SNP)

will help manage all of these benefits for you, so that you get the health care services and

payment assistance that you are entitled to.

MetroPlus Advantage Plan (HMO SNP) is run by a non-profit organization. Like all Medicare

Advantage Plans, this Medicare Special Needs Plan is approved by Medicare. We are pleased to

be providing your Medicare health care coverage, including your prescription drug coverage.

https://www.irs.gov/Affordable-Care-Act/Individuals-and-Families



Section 1.2 What is the Evidence of Coverage booklet about?

This Evidence of Coverage booklet tells you how to get your Medicare and Medicaid medical

care and prescription drugs covered through our plan. This booklet explains your rights and

responsibilities, what is covered, and what you pay as a member of the plan.

The word “coverage” and “covered services” refers to the medical care and services and the

prescription drugs available to you as a member of MetroPlus Advantage Plan (HMO SNP).

It’s important for you to learn what the plan’s rules are and what services are available to you.

We encourage you to set aside some time to look through this Evidence of Coverage booklet.

If you are confused or concerned or just have a question, please contact our plan’s Member

Services (phone numbers are printed on the back cover of this booklet).

Section 1.3 Legal information about the Evidence of Coverage

It’s part of our contract with you

This Evidence of Coverage is part of our contract with you about how MetroPlus Advantage

Plan (HMO SNP) covers your care. Other parts of this contract include your enrollment form, the

List of Covered Drugs (Formulary), and any notices you receive from us about changes to your

coverage or conditions that affect your coverage. These notices are sometimes called “riders” or

“amendments.”

The contract is in effect for months in which you are enrolled in MetroPlus Advantage Plan

(HMO SNP) between January 1, 2019, and December 31, 2019.

Each calendar year, Medicare allows us to make changes to the plans that we offer. This means

we can change the costs and benefits of MetroPlus Advantage Plan (HMO SNP) after December

31, 2019. We can also choose to stop offering the plan, or to offer it in a different service area,

after December 31, 2019.

Medicare must approve our plan each year

Medicare (the Centers for Medicare & Medicaid Services) must approve MetroPlus Advantage

Plan (HMO SNP) each year. You can continue to get Medicare coverage as a member of our

plan as long as we choose to continue to offer the plan and Medicare renews its approval of the

plan.



SECTION 2 What makes you eligible to be a plan member?

Section 2.1 Your eligibility requirements

You are eligible for membership in our plan as long as:

• You have both Medicare Part A and Medicare Part B (Section 2.2 tells you about

Medicare Part A and Medicare Part B)

• -- and -- You live in our geographic service area (Section 2.3 below describes our service

area).

• -- and -- you are a United States citizen or are lawfully present in the United States

• -- and -- You do not have End-Stage Renal Disease (ESRD), with limited exceptions,

such as if you develop ESRD when you are already a member of a plan that we offer, or

you were a member of a different plan that was terminated.

• -- and -- You meet the special eligibility requirements described below.

Special eligibility requirements for our plan

Our plan is designed to meet the needs of people who receive certain Medicaid benefits.

(Medicaid is a joint Federal and state government program that helps with medical costs for

certain people with limited incomes and resources.) To be eligible for our plan you must be

eligible for both Medicare and Medicaid.

Please note: If you lose your eligibility but can reasonably be expected to regain eligibility

within 90 days, then you are still eligible for membership in our plan (Chapter 4, Section 2.1 tells

you about coverage and cost-sharing during a period of deemed continued eligibility).

Section 2.2 What are Medicare Part A and Medicare Part B?

When you first signed up for Medicare, you received information about what services are

covered under Medicare Part A and Medicare Part B. Remember:

• Medicare Part A generally helps cover services provided by hospitals (for inpatient

services, skilled nursing facilities, or home health agencies).

• Medicare Part B is for most other medical services (such as physician’s services and

other outpatient services) and certain items (such as durable medical equipment (DME)

and supplies).



Section 2.3 What is Medicaid?

Medicaid is a joint Federal and state government program that helps with medical costs for

certain people who have limited incomes and resources. Each state decides what counts as

income and resources, who is eligible, what services are covered, and the cost for services. States

also can decide how to run their program as long as they follow the Federal guidelines.

In addition, there are programs offered through Medicaid that help people with Medicare pay

their Medicare costs, such as their Medicare premiums. These “Medicare Savings Programs” help people with limited income and resources save money each year:

• Qualified Medicare Beneficiary (QMB): Helps pay Medicare Part A and Part B

premiums, and other cost-sharing (like deductibles, coinsurance, and copayments). (Some

people with QMB are also eligible for full Medicaid benefits (QMB+).)

• Specified Low-Income Medicare Beneficiary (SLMB): Helps pay Part B premiums.

(Some people with SLMB are also eligible for full Medicaid benefits (SLMB+).)

• Qualifying Individual (QI): Helps pay Part B premiums

• Qualified Disabled & Working Individuals (QDWI): Helps pay Part A premiums

Section 2.4 Here is the plan service area for MetroPlus Advantage Plan (HMO SNP)

Although Medicare is a Federal program, MetroPlus Advantage Plan (HMO SNP) is available

only to individuals who live in our plan service area. To remain a member of our plan, you must

continue to reside in the plan service area. The service area is described below.

Our service area includes these counties in New York: Bronx, Kings (Brooklyn), Queens,

Richmond (Staten Island), and New York (Manhattan)

If you plan to move out of the service area, please contact Member Services (phone numbers are

printed on the back cover of this booklet). When you move, you will have a Special Enrollment

Period that will allow you to switch to Original Medicare or enroll in a Medicare health or drug

plan that is available in your new location.

It is also important that you call Social Security if you move or change your mailing address.

You can find phone numbers and contact information for Social Security in Chapter 2, Section 5.

Section 2.5 U.S. Citizen or Lawful Presence

A member of a Medicare health plan must be a U.S. citizen or lawfully present in the United

States. Medicare (the Centers for Medicare & Medicaid Services) will notify MetroPlus

Advantage Plan (HMO SNP) if you are not eligible to remain a member on this basis. MetroPlus

Advantage Plan (HMO SNP) must disenroll you if you do not meet this requirement.



SECTION 3 What other materials will you get from us?

Section 3.1 Your plan membership card – Use it to get all covered care and prescription drugs

While you are a member of our plan, you must use your membership card for our plan whenever

you get any services covered by this plan and for prescription drugs you get at network

pharmacies. You should also show the provider your Medicaid card. Here’s a sample membership card to show you what yours will look like:

As long as you are a member of our plan, in most cases, you must not use your new red, white,

and blue Medicare card to get covered medical services (with the exception of routine clinical

research studies and hospice services). You may be asked to show your new Medicare card if

you need hospital services. Keep your new red, white, and blue Medicare card in a safe place in

case you need it later.

Here’s why this is so important: If you get covered services using your new red, white, and

blue Medicare card instead of using your MetroPlus Advantage Plan (HMO SNP) membership

card while you are a plan member, you may have to pay the full cost yourself.

If your plan membership card is damaged, lost, or stolen, call Member Services right away and

we will send you a new card. (Phone numbers for Member Services are printed on the back cover

of this booklet.)

Section 3.2 The Provider/Pharmacy Directory: Your guide to all providers in the plan’s network

The Provider/Pharmacy Directory lists our network providers and durable medical equipment

suppliers. The directory also includes participating Medicaid providers.



What are “network providers”?

Network providers are the doctors and other health care professionals, medical groups, durable

medical equipment suppliers, hospitals, and other health care facilities that have an agreement

with us to accept our payment and any plan cost-sharing as payment in full. We have arranged

for these providers to deliver covered services to members in our plan. The most recent list of

providers and suppliers is available on our website at www.metroplusmedicare.org.

Why do you need to know which providers are part of our network?

It is important to know which providers are part of our network because, with limited exceptions,

while you are a member of our plan you must use network providers to get your medical care and

services. The only exceptions are emergencies, urgently needed services when the network is not

available (generally, when you are out of the area), out-of-area dialysis services, and cases in

which MetroPlus Advantage Plan (HMO SNP) authorizes use of out-of-network providers. See

Chapter 3 (Using the plan’s coverage for your medical services) for more specific information

about emergency, out-of-network, and out-of-area coverage.

It is important to know who the participating Medicaid providers are. You must go to Medicaid

providers to get Medicaid services provided by the plan. To find network providers who also

accept New York State Medicaid, look for the Medicaid indicator next to the provider’s name in

the Provider/Pharmacy Directory.

If you don’t have your copy of the Provider/Pharmacy Directory, you can request a copy from

Member Services (phone numbers are printed on the back cover of this booklet). You may ask

Member Services for more information about our network providers, including their

qualifications. You can also see the Provider Directory at www.metroplusmedicare.org, or

download it from this website. Both Member Services and the website can give you the most up-

to-date information about changes in our network providers.

What are “network pharmacies”?

Network pharmacies are all of the pharmacies that have agreed to fill covered prescriptions for

our plan members.

Why do you need to know about network pharmacies?

You can use the Provider/Pharmacy Directory to find the network pharmacy you want to use.

There are changes to our network of pharmacies for next year. An updated Provider/Pharmacy

Directory is located on our website at www.metroplusmedicare.org. You may also call Member

Services for updated provider information or to ask us to mail you a Provider/Pharmacy

Directory. Please review the 2019 Provider/Pharmacy Directory to see which pharmacies

are in our network.

If you don’t have the Provider/Pharmacy Directory, you can get a copy from Member Services

(phone numbers are printed on the back cover of this booklet). At any time, you can call Member

www.metroplusmedicare.org





Services to get up-to-date information about changes in the pharmacy network. You can also find

this information on our website at www.metroplusmedicare.org.

Section 3.3 The plan’s List of Covered Drugs (Formulary)

The plan has a List of Covered Drugs (Formulary). We call it the “Drug List” for short. It tells

which prescription drugs are covered by MetroPlus Advantage Plan (HMO SNP). The drugs on

this list are selected by the plan with the help of a team of doctors and pharmacists. The list must

meet requirements set by Medicare and Medicaid. Medicare and Medicaid have approved the

MetroPlus Advantage Plan (HMO SNP) Drug List.

The Drug List also tells you if there are any rules that restrict coverage for your drugs.

We will provide you a copy of the Drug List. To get the most complete and current information

about which drugs are covered, you can visit the plan’s website (www.metroplusmedicare.org)

or call Member Services (phone numbers are printed on the back cover of this booklet).

Section 3.4 The Part D Explanation of Benefits (the “Part D EOB”): Reports with a summary of payments made for your Part D prescription drugs

When you use your Part D prescription drug benefits, we will send you a summary report to help

you understand and keep track of payments for your Part D prescription drugs. This summary

report is called the Part D Explanation of Benefits (or the “Part D EOB”).

The Part D Explanation of Benefits tells you the total amount you, or others on your behalf, have

spent on your Part D prescription drugs and the total amount we have paid for each of your Part

D prescription drugs during the month. Chapter 6 (What you pay for your Part D prescription

drugs) gives more information about the Explanation of Benefits and how it can help you keep

track of your drug coverage.

A Part D Explanation of Benefits summary is also available upon request. To get a copy, please

contact Member Services (phone numbers are printed on the back cover of this booklet).

SECTION 4 Your monthly premium for MetroPlus Advantage Plan (HMO SNP)

Section 4.1 How much is your plan premium?

As a member of our plan, you pay a monthly plan premium. For 2019, the monthly premium for

MetroPlus Advantage Plan (HMO SNP) is $0 or $39. In addition, you must continue to pay your

Medicare Part B premium (unless your Part B premium is paid for you by Medicaid or another

third party).





In some situations, your plan premium could be more

In some situations, your plan premium could be more than the amount listed above in Section

4.1. This situation is described below.

• Some members are required to pay a Part D late enrollment penalty because they did

not join a Medicare drug plan when they first became eligible or because they had a

continuous period of 63 days or more when they didn’t have “creditable” prescription

drug coverage. (“Creditable” means the drug coverage is expected to pay, on average, at

least as much as Medicare’s standard prescription drug coverage.) For these members, the

Part D late enrollment penalty is added to the plan’s monthly premium. Their premium

amount will be the monthly plan premium plus the amount of their Part D late enrollment

penalty.

o If you receive “Extra Help” from Medicare to pay for your prescription drugs, you

will not pay a late enrollment penalty.

o If you ever lose your low income subsidy (“Extra Help”), you would be subject to

the monthly Part D late enrollment penalty if you have ever gone without

creditable prescription drug coverage for 63 days or more.

o If you are required to pay the Part D late enrollment penalty, the cost of the late

enrollment penalty depends on how long you went without Part D or creditable

prescription drug coverage.

Some members are required to pay other Medicare premiums

In addition to paying the monthly plan premium, some members are required to pay other

Medicare premiums. As explained in Section 2 above, in order to be eligible for our plan, you

must maintain your eligibility for Medicaid as well as have both Medicare Part A and Medicare

Part B. For most MetroPlus Advantage Plan (HMO SNP) members, Medicaid pays for your Part

A premium (if you don’t qualify for it automatically) and for your Part B premium. If Medicaid

is not paying your Medicare premiums for you, you must continue to pay your Medicare

premiums to remain a member of the plan.

Some people pay an extra amount for Part D because of their yearly income; this is known as

Income Related Monthly Adjustment Amounts, also known as IRMAA. If your income is greater

than $85,000 for an individual (or married individuals filing separately) or greater than $170,000

for married couples, you must pay an extra amount directly to the government (not the

Medicare plan) for your Medicare Part D coverage.

• If you have to pay an extra amount, Social Security, not your Medicare plan, will send

you a letter telling you what that extra amount will be. If you had a life-changing event

that caused your income to go down, you can ask Social Security to reconsider their

decision.

• If you are required to pay the extra amount and you do not pay it, you will be

disenrolled from the plan.



• You can also visit https://www.medicare.gov on the Web or call 1-800-MEDICARE (1-

800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-

2048. Or you may call Social Security at 1-800-772-1213. TTY users should call 1-800-

325-0778.

Your copy of Medicare & You 2019 gives information about these premiums in the section

called “2019 Medicare Costs.” Everyone with Medicare receives a copy of Medicare & You

each year in the fall. Those new to Medicare receive it within a month after first signing up. You

can also download a copy of Medicare & You 2019 from the Medicare website

(https://www.medicare.gov). Or, you can order a printed copy by phone at 1-800-MEDICARE

(1-800-633-4227), 24 hours a day, 7 days a week. TTY users call 1-877-486-2048.

Section 4.2 There are several ways you can pay your plan premium

There are two ways you can pay your plan premium. Members select their payment option of

choice on their application at the time of enrollment. To change the way you pay your premium,

please call Member Services.

If you decide to change the way you pay your premium, it can take up to three months for your

new payment method to take effect. While we are processing your request for a new payment

method, you are responsible for making sure that your plan premium is paid on time.

Option 1: You can pay by check

You may decide to pay your premium directly to our Plan with a check or money order. You will

receive an invoice from our Plan every month. Please make payment payable to “MetroPlus

Health Plan”. Payments should be sent to:

MetroPlus Health Plan

PO Box 30327

New York, NY 10087

Full payment must be received by the end of the month in which you get the invoice. For

example, your January monthly premium is due by January 31st.

Option two: You can have the plan premium taken out of your monthly Social Security check

You can have the plan premium taken out of your monthly Social Security check. Contact

Member Services for more information on how to pay your monthly plan premium this way. We

will be happy to help you set this up. (Phone numbers for Member Services are printed on the

back cover of this booklet.)

https://www.medicare.gov/




What to do if you are having trouble paying your plan premium

Your plan premium is due in our office by the last day of the month. If we have not received

your premium by the last day of the month, we will send you a notice telling you that your plan

membership will end if we do not receive your premium payment within 90 days. If you are

required to pay a Part D late enrollment penalty, you must pay the penalty to keep your

prescription drug coverage.

If you are having trouble paying your premium on time, please contact Member Services to see if

we can direct you to programs that will help with your plan premium. (Phone numbers for

Member Services are printed on the back cover of this booklet.)

If we end your membership because you did not pay your plan premium, you will have health

coverage under Original Medicare. As long as you are receiving “Extra Help” with your

prescription drug costs, you will continue to have Part D drug coverage. Medicare will enroll you

into a new prescription drug plan for your Part D coverage.

At the time we end your membership, you may still owe us for premiums you have not paid. We

have the right to pursue collection of the premiums you owe. In the future, if you want to enroll

again in our plan (or another plan that we offer), you will need to pay the amount you owe before

you can enroll.

If you think we have wrongfully ended your membership, you have a right to ask us to

reconsider this decision by making a complaint. Chapter 9, Section 11 of this booklet tells how to

make a complaint. If you had an emergency circumstance that was out of your control and it

caused you to not be able to pay your premiums within our grace period, you can ask us to

reconsider this decision by calling 1-866-986-0356 24 hours a day, 7 days a week. TTY users

should call 711. You must make your request no later than 60 days after the date your

membership ends.

Section 4.3 Can we change your monthly plan premium during the year?

No. We are not allowed to change the amount we charge for the plan’s monthly plan premium

during the year. If the monthly plan premium changes for next year, we will tell you in

September and the change will take effect on January 1.

SECTION 5 Please keep your plan membership record up to date

Section 5.1 How to help make sure that we have accurate information about you

Your membership record has information from your enrollment form, including your address and

telephone number. It shows your specific plan coverage including your Primary Care Provider.



The doctors, hospitals, pharmacists, and other providers in the plan’s network need to have correct information about you. These network providers use your membership record to

know what services and drugs are covered and the cost-sharing amounts for you. Because

of this, it is very important that you help us keep your information up to date.

Let us know about these changes:

• Changes to your name, your address, or your phone number

• Changes in any other health insurance coverage you have (such as from your employer,

your spouse’s employer, workers’ compensation, or Medicaid)

• If you have any liability claims, such as claims from an automobile accident

• If you have been admitted to a nursing home

• If you receive care in an out-of-area or out-of-network hospital or emergency room

• If your designated responsible party (such as a caregiver) changes

• If you are participating in a clinical research study

If any of this information changes, please let us know by calling Member Services (phone

numbers are printed on the back cover of this booklet).

It is also important to contact Social Security if you move or change your mailing address. You

can find phone numbers and contact information for Social Security in Chapter 2, Section 5.

You can also contact the Human Resources Agency (HRA) directly to report income changes to

the State program.

Human Resources Administration

505 Clermont Avenue

Brooklyn, NY 11238

General Infoline:718-557-1399

Read over the information we send you about any other insurance coverage you have

Medicare requires that we collect information from you about any other medical or drug

insurance coverage that you have. That’s because we must coordinate any other coverage you

have with your benefits under our plan. (For more information about how our coverage works

when you have other insurance, see Section 7 in this chapter.)

Once each year, we will send you a letter that lists any other medical or drug insurance coverage

that we know about. Please read over this information carefully. If it is correct, you don’t need to

do anything. If the information is incorrect, or if you have other coverage that is not listed, please

call Member Services (phone numbers are printed on the back cover of this booklet).



SECTION 6 We protect the privacy of your personal health information

Section 6.1 We make sure that your health information is protected

Federal and state laws protect the privacy of your medical records and personal health

information. We protect your personal health information as required by these laws.

For more information about how we protect your personal health information, please go to

Chapter 8, Section 1.4 of this booklet.

SECTION 7 How other insurance works with our plan

Section 7.1 Which plan pays first when you have other insurance?

When you have other insurance (like employer group health coverage), there are rules set by

Medicare that decide whether our plan or your other insurance pays first. The insurance that pays

first is called the “primary payer” and pays up to the limits of its coverage. The one that pays

second, called the “secondary payer,” only pays if there are costs left uncovered by the primary

coverage. The secondary payer may not pay all of the uncovered costs.

These rules apply for employer or union group health plan coverage:

• If you have retiree coverage, Medicare pays first.

• If your group health plan coverage is based on your or a family member’s current

employment, who pays first depends on your age, the number of people employed by

your employer, and whether you have Medicare based on age, disability, or End-Stage

Renal Disease (ESRD):

o If you’re under 65 and disabled and you or your family member is still working,

your group health plan pays first if the employer has 100 or more employees or at

least one employer in a multiple employer plan that has more than 100 employees.

o If you’re over 65 and you or your spouse is still working, your group health plan

pays first if the employer has 20 or more employees or at least one employer in a

multiple employer plan that has more than 20 employees.

• If you have Medicare because of ESRD, your group health plan will pay first for the first

30 months after you become eligible for Medicare.

These types of coverage usually pay first for services related to each type:

• No-fault insurance (including automobile insurance)

• Liability (including automobile insurance)



• Black lung benefits

• Workers’ compensation

Medicaid and TRICARE never pay first for Medicare-covered services. They only pay after

Medicare and/or employer group health plans have paid.

If you have other insurance, tell your doctor, hospital, and pharmacy. If you have questions about

who pays first, or you need to update your other insurance information, call Member Services

(phone numbers are printed on the back cover of this booklet). You may need to give your plan

member ID number to your other insurers (once you have confirmed their identity) so your bills

are paid correctly and on time.

CHAPTER 2

Important phone numbers and resources


Chapter 2. Important phone numbers and resources


SECTION 1 MetroPlus Advantage Plan (HMO SNP) contacts (how to contact us, including how to reach Member Services at the plan) ...... 21

SECTION 2 Medicare (how to get help and information directly from the Federal Medicare program) ................................................................ 28

SECTION 3 State Health Insurance Assistance Program (free help, information, and answers to your questions about Medicare) ............ 30

SECTION 4 Quality Improvement Organization (paid by Medicare to check on the quality of care for people with Medicare)....................... 31

SECTION 5 Social Security.................................................................................. 32

SECTION 6 Medicaid (a joint Federal and state program that helps with medical costs for some people with limited income and resources) .......................................................................................... 33

SECTION 7 Information about programs to help people pay for their prescription drugs............................................................................ 34

SECTION 8 How to contact the Railroad Retirement Board ............................. 38

SECTION 9 Do you have “group insurance” or other health insurance from an employer? ........................................................................... 38



SECTION 1 MetroPlus Advantage Plan (HMO SNP) contacts (how to contact us, including how to reach Member Services at the plan)

How to contact our plan’s Member Services

For assistance with claims, billing, or member card questions, please call or write to MetroPlus

Advantage Plan (HMO SNP) Member Services. We will be happy to help you.

Method Member Services – Contact Information

CALL 1-866-986-0356

Calls to this number are free.

24 hours a day, 7 days a week

Member Services also has free language interpreter services available

for non-English speakers.

TTY 711

This number requires special telephone equipment and is only for

people who have difficulties with hearing or speaking.



FAX 212-908-5196

WRITE MetroPlus Health Plan

160 Water Street, 3rd Floor

New York, NY 10038

Attn: Medicare Department

WEBSITE www.metroplusmedicare.org



How to contact us when you are asking for a coverage decision about your medical care

A coverage decision is a decision we make about your benefits and coverage or about the

amount we will pay for your medical services. For more information on asking for coverage

decisions about your medical care, see Chapter 9 (What to do if you have a problem or

complaint (coverage decisions, appeals, complaints)).

You may call us if you have questions about our coverage decision process.

Method Coverage Decisions for Medical Care – Contact Information

CALL 1-866-986-0356



TTY 711





FAX 212-908-5196



New York, NY 10038





How to contact us when you are making an appeal about your medical care

An appeal is a formal way of asking us to review and change a coverage decision we have

made. For more information on making an appeal about your medical care, see Chapter 9

(What to do if you have a problem or complaint (coverage decisions, appeals, complaints)).

Method Appeals for Medical Care – Contact Information

CALL 1-866-986-0356



TTY 711





FAX 212-908-5196



New York, NY 10038





How to contact us when you are making a complaint about your medical care

You can make a complaint about us or one of our network providers, including a complaint

about the quality of your care. This type of complaint does not involve coverage or payment

disputes. (If your problem is about the plan’s coverage or payment, you should look at the

section above about making an appeal.) For more information on making a complaint about

your medical care, see Chapter 9 (What to do if you have a problem or complaint (coverage

decisions, appeals, complaints)).

Method Complaints about Medical Care – Contact Information

CALL 1-866-986-0356



TTY 711





FAX 212-908-5196



New York, NY 10038


MEDICARE

WEBSITE

You can submit a complaint about MetroPlus Advantage Plan (HMO

SNP) directly to Medicare. To submit an online complaint to Medicare

go to https://www.medicare.gov/MedicareComplaintForm/home.aspx.

https://www.medicare.gov/MedicareComplaintForm/home.aspx



How to contact us when you are asking for a coverage decision about your Part B and Part D prescription drugs

A coverage decision is a decision we make about your benefits and coverage or about the

amount we will pay for your prescription drugs covered under the Part B and Part D benefit

included in your plan. For more information on asking for coverage decisions about your Part

B and Part D prescription drugs, see Chapter 9 (What to do if you have a problem or

complaint (coverage decisions, appeals, complaints).

Method Coverage Decisions for Part B and Part D Prescription Drugs – Contact Information

CALL 1-866-986-0356



TTY 711





FAX 212-908-5196



New York, NY 10038





How to contact us when you are making an appeal about your Part B and Part D prescription drugs

An appeal is a formal way of asking us to review and change a coverage decision we have

made. For more information on making an appeal about your Part B and Part D prescription

drugs, see Chapter 9 (What to do if you have a problem or complaint (coverage decisions,

appeals, complaints)).

Method Appeals for Part B and Part D Prescription Drugs – Contact

Information

CALL 1-866-986-0356



TTY 711





FAX 212-908-5196



New York, NY 10038



http://www.metroplusmedicare.org/



How to contact us when you are making a complaint about your Part B and Part D prescription drugs

You can make a complaint about us or one of our network pharmacies, including a complaint

about the quality of your care. This type of complaint does not involve coverage or payment

disputes. (If your problem is about the plan’s coverage or payment, you should look at the section above about making an appeal.) For more information on making a complaint about

your Part B and Part prescription drugs, see Chapter 9 (What to do if you have a problem or

complaint (coverage decisions, appeals, complaints).

Method Complaints about Part B and Part D prescription drugs – Contact

Information

CALL 1-866-986-0356



TTY 711





FAX 212-908-5196



New York, NY 10038


MEDICARE

WEBSITE

You can submit a complaint about MetroPlus Advantage Plan (HMO

SNP) directly to Medicare. To submit an online complaint to Medicare

go to https://www.medicare.gov/MedicareComplaintForm/home.aspx.

Where to send a request asking us to pay for our share of the cost for medical care or a drug you have received

For more information on situations in which you may need to ask us for reimbursement or to

pay a bill you have received from a provider, see Chapter 7 (Asking us to pay our share of a

bill you have received for covered medical services or drugs).

Please note: If you send us a payment request and we deny any part of your request, you can

appeal our decision. See Chapter 9 (What to do if you have a problem or complaint (coverage

decisions, appeals, complaints)) for more information.




Method Payment Request – Contact Information

CALL 1-866-986-0356

24 hours a day, 7 days a week Calls to this number are free.

TTY 711





FAX 212-908-5196



New York, NY 10038



SECTION 2 Medicare (how to get help and information directly from the Federal Medicare program)

Medicare is the Federal health insurance program for people 65 years of age or older, some

people under age 65 with disabilities, and people with End-Stage Renal Disease (permanent

kidney failure requiring dialysis or a kidney transplant).

The Federal agency in charge of Medicare is the Centers for Medicare & Medicaid Services

(sometimes called “CMS”). This agency contracts with Medicare Advantage organizations

including us.

Method Medicare – Contact Information

CALL 1-800-MEDICARE, or 1-800-633-4227


24 hours a day, 7 days a week.



Method Medicare – Contact Information

TTY 1-877-486-2048

This number requires special telephone equipment and is only for people who

have difficulties with hearing or speaking.


WEBSITE https://www.medicare.gov

This is the official government website for Medicare. It gives you up-to-date

information about Medicare and current Medicare issues. It also has

information about hospitals, nursing homes, physicians, home health

agencies, and dialysis facilities. It includes booklets you can print directly

from your computer. You can also find Medicare contacts in your state.

The Medicare website also has detailed information about your Medicare

eligibility and enrollment options with the following tools:

• Medicare Eligibility Tool: Provides Medicare eligibility status

information.

• Medicare Plan Finder: Provides personalized information about

available Medicare prescription drug plans, Medicare health plans, and

Medigap (Medicare Supplement Insurance) policies in your area.

These tools provide an estimate of what your out-of-pocket costs

might be in different Medicare plans.

WEBSITE

(continued)

You can also use the website to tell Medicare about any complaints you have

about MetroPlus Advantage Plan (HMO SNP):

• Tell Medicare about your complaint: You can submit a complaint

about MetroPlus Advantage Plan (HMO SNP) directly to Medicare.

To submit a complaint to Medicare, go to

https://www.medicare.gov/MedicareComplaintForm/home.aspx.

Medicare takes your complaints seriously and will use this

information to help improve the quality of the Medicare program.

If you don’t have a computer, your local library or senior center may be able

to help you visit this website using its computer. Or, you can call Medicare

and tell them what information you are looking for. They will find the

information on the website, print it out, and send it to you. (You can call

Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a

week. TTY users should call 1-877-486-2048.)





SECTION 3 State Health Insurance Assistance Program (free help, information, and answers to your questions about Medicare)

The State Health Insurance Assistance Program (SHIP) is a government program with trained

counselors in every state. In New York, the SHIP is called New York State Health Insurance

Information Counseling and Assistance (HIICAP).

HIICAP is independent (not connected with any insurance company or health plan). It is a state

program that gets money from the Federal government to give free local health insurance

counseling to people with Medicare.

HIICAP counselors can help you with your Medicare questions or problems. They can help you

understand your Medicare rights, help you make complaints about your medical care or

treatment, and help you straighten out problems with your Medicare bills. HIICAP counselors

can also help you understand your Medicare plan choices and answer questions about switching

plans.

Method HIICAP (New York’s SHIP) – Contact Information

CALL 1-800-701-0501

WRITE New York City Department for the Aging

2 Lafayette Street, 16th Floor

New York, NY 10007

WEBSITE www.aging.ny.gov/healthbenefits



SECTION 4 Quality Improvement Organization (paid by Medicare to check on the quality of care for people with Medicare)

There is a designated Quality Improvement Organization for serving Medicare beneficiaries in

each state. For New York, the Quality Improvement Organization is called Livanta.

Livanta has a group of doctors and other health care professionals who are paid by the Federal

government. This organization is paid by Medicare to check on and help improve the quality of

care for people with Medicare. Livanta is an independent organization. It is not connected with

our plan.

You should contact Livanta in any of these situations:

• You have a complaint about the quality of care you have received.

• You think coverage for your hospital stay is ending too soon.

• You think coverage for your home health care, skilled nursing facility care, or

Comprehensive Outpatient Rehabilitation Facility (CORF) services are ending too soon.

Method Livanta (New York’s Quality Improvement Organization) – Contact Information

CALL 1-866-815-5440

TTY 1-866-868-2289

WRITE Livanta LLC

BFCC-QIO

10820 Guilford Road, Suite 202

Annapolis Junction, MD 20701-1105

[email protected]

WEBSITE www.bfccqioarea1.com/



SECTION 5 Social Security

Social Security is responsible for determining eligibility and handling enrollment for Medicare.

U.S. citizens and lawful permanent residents who are 65 or older, or who have a disability or

End-Stage Renal Disease and meet certain conditions, are eligible for Medicare. If you are

already getting Social Security checks, enrollment into Medicare is automatic. If you are not

getting Social Security checks, you have to enroll in Medicare. Social Security handles the

enrollment process for Medicare. To apply for Medicare, you can call Social Security or visit

your local Social Security office.

Social Security is also responsible for determining who has to pay an extra amount for their Part

D drug coverage because they have a higher income. If you got a letter from Social Security

telling you that you have to pay the extra amount and have questions about the amount or if your

income went down because of a life-changing event, you can call Social Security to ask for

reconsideration.

If you move or change your mailing address, it is important that you contact Social Security to

let them know.

Method Social Security – Contact Information

CALL 1-800-772-1213


Available 7:00 am to 7:00 pm, Monday through Friday.

You can use Social Security’s automated telephone services to get

recorded information and conduct some business 24 hours a day.

TTY 1-800-325-0778




Available 7:00 am to 7:00 pm, Monday through Friday.

WEBSITE https://www.ssa.gov

https://www.ssa.gov/



SECTION 6 Medicaid (a joint Federal and state program that helps with medical costs for some people with limited income and resources)

Medicaid is a joint Federal and state government program that helps with medical costs for

certain people with limited incomes and resources. Members of MetroPlus Advantage Plan

(HMO SNP) are dually enrolled with both Medicare and Medicaid.

In addition, there are programs offered through Medicaid that help people with Medicare pay

their Medicare costs, such as their Medicare premiums. These “Medicare Savings Programs” help people with limited income and resources save money each year:

• Qualified Medicare Beneficiary (QMB): Helps pay Medicare Part A and Part B

premiums, and other cost-sharing (like deductibles, coinsurance, and copayments). (Some

people with QMB are also eligible for full Medicaid benefits (QMB+).)

• Specified Low-Income Medicare Beneficiary (SLMB): Helps pay Part B premiums.

(Some people with SLMB are also eligible for full Medicaid benefits (SLMB+).)

• Qualified Individual (QI): Helps pay Part B premiums

• Qualified Disabled & Working Individuals (QDWI): Helps pay Part A premiums

If you have questions about the assistance you get from Medicaid, contact New York City

Human Resources Administration.

Method Human Resources Administration (New York’s Medicaid program) – Contact Information

CALL 718-557-1399

WRITE 505 Clermont Avenue

Brooklyn, NY 11238

WEBSITE www.nyc.gov/html/hra



Community Health Advocates helps people enrolled in Medicaid with service or billing

problems. They can help you file a grievance or appeal with our plan.

Method Community Health Advocates – Contact Information

CALL 1-888-614-5400

TTY 711



WRITE Call for a location near you

The Independent Consumer Advocacy Network helps people get information about nursing

homes and resolve problems between nursing homes and residents or their families.

Method Independent Consumer Advocacy Network– Contact Information

CALL 844-614-8800

TTY 711



WRITE Call for a location near you

SECTION 7 Information about programs to help people pay for their prescription drugs

Medicare’s “Extra Help” Program

Most of our members qualify for and are already getting “Extra Help” from Medicare to pay for their prescription drug plan costs.

Medicare provides “Extra Help” to pay prescription drug costs for people who have limited

income and resources. Resources include your savings and stocks, but not your home or car.

Those who qualify get help paying for any Medicare drug plan’s monthly premium, yearly deductible, and prescription copayments. This “Extra Help” also counts toward your out-of-

pocket costs.



People with limited income and resources may qualify for “Extra Help.” Some people

automatically qualify for “Extra Help” and don’t need to apply. Medicare mails a letter to people who automatically qualify for “Extra Help.”

If you have questions about “Extra Help,” call:

• 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours

a day, 7 days a week;

• The Social Security Office at 1-800-772-1213, between 7 am to 7 pm, Monday through

Friday. TTY users should call 1-800-325-0778; or

• Your State Medicaid Office (See Section 6 of this chapter for contact information).

If you believe you have qualified for “Extra Help” and you believe that you are paying an

incorrect cost-sharing amount when you get your prescription at a pharmacy, our plan has

established a process that allows you to either request assistance in obtaining evidence of your

proper copayment level, or, if you already have the evidence, to provide this evidence to us.

• To request assistance with obtaining best available evidence or information on how to

send it to MetroPlus, call Member Services (phone numbers are on the back of this

booklet).

• When we receive the evidence showing your copayment level, we will update our system

so that you can pay the correct copayment when you get your next prescription at the

pharmacy. If you overpay your copayment, we will reimburse you. Either we will

forward a check to you in the amount of your overpayment or we will offset future

copayments. If the pharmacy hasn’t collected a copayment from you and is carrying your copayment as a debt owed by you, we may make the payment directly to the pharmacy. If

a state paid on your behalf, we may make payment directly to the state. Please contact

Member Services if you have questions (phone numbers are printed on the back cover of

this booklet).

What if you have coverage from a State Pharmaceutical Assistance Program (SPAP)?

If you are enrolled in a State Pharmaceutical Assistance Program (SPAP), or any other program

that provides coverage for Part D drugs (other than “Extra Help”), you still get the 70% discount

on covered brand name drugs. Also, the plan pays 5% of the costs of brand drugs in the coverage

gap. The 70% discount and the 5% paid by the plan are both applied to the price of the drug

before any SPAP or other coverage.

What if you have coverage from an AIDS Drug Assistance Program (ADAP)?

What is the AIDS Drug Assistance Program (ADAP)?

The AIDS Drug Assistance Program (ADAP) helps ADAP-eligible individuals living with

HIV/AIDS have access to life-saving HIV medications. Medicare Part D prescription drugs that

are also covered by ADAP qualify for prescription cost-sharing assistance. The New York State

Department of Health offers an ADAP for residents of New York. Note: To be eligible for the



ADAP operating in your State, individuals must meet certain criteria, including proof of State

residence and HIV status, low income as defined by the State, and uninsured/under-insured

status.

If you are currently enrolled in an ADAP, it can continue to provide you with Medicare Part D

prescription cost-sharing assistance for drugs on the ADAP formulary. In order to be sure you

continue receiving this assistance, please notify your local ADAP enrollment worker of any

changes in your Medicare Part D plan name or policy number. Contact the New York ADAP at

1-800-542-2437.

For information on eligibility criteria, covered drugs, or how to enroll in the program, please call

1-800-542-2437.

What if you get “Extra Help” from Medicare to help pay your prescription drug costs?

Can you get the discounts?

Most of our members get “Extra Help” from Medicare to pay for their prescription drug plan

costs. If you get “Extra Help,” the Medicare Coverage Gap Discount Program does not apply to

you. If you get “Extra Help,” you already have coverage for your prescription drug costs during

the coverage gap.

What if you don’t get a discount, and you think you should have?

If you think that you have reached the coverage gap and did not get a discount when you paid for

your brand name drug, you should review your next Part D Explanation of Benefits (Part D

EOB) notice. If the discount doesn’t appear on your Part D Explanation of Benefits, you should

contact us to make sure that your prescription records are correct and up-to-date. If we don’t

agree that you are owed a discount, you can appeal. You can get help filing an appeal from your

State Health Insurance Assistance Program (SHIP) (telephone numbers are in Section 3 of this

Chapter) or by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week.

TTY users should call 1-877-486-2048.



State Pharmaceutical Assistance Programs

Many states have State Pharmaceutical Assistance Programs that help some people pay for

prescription drugs based on financial need, age, medical condition, or disabilities. Each state has

different rules to provide drug coverage to its members.

In New York, the State Pharmaceutical Assistance Program is Elderly Pharmaceutical Insurance

Coverage (EPIC).

Method EPIC (New York’s State Pharmaceutical Assistance Program) – Contact Information

CALL 1-800-332-3742

8:30am-5pm, Monday-Friday

TTY 1-800-290-9138



WRITE EPIC

P.O. Box 15018

Albany, NY 12212-5018

[email protected].

WEBSITE www.health.ny.gov/health_care/epic



SECTION 8 How to contact the Railroad Retirement Board

The Railroad Retirement Board is an independent Federal agency that administers

comprehensive benefit programs for the nation’s railroad workers and their families. If you have

questions regarding your benefits from the Railroad Retirement Board, contact the agency.

If you receive your Medicare through the Railroad Retirement Board, it is important that you let

them know if you move or change your mailing address.

Method Railroad Retirement Board – Contact Information

CALL 1-877-772-5772


Available 9:00 am to 3:30 pm, Monday through Friday

If you have a touch-tone telephone, recorded information and

automated services are available 24 hours a day, including weekends

and holidays.

TTY 1-312-751-4701



Calls to this number are not free.

WEBSITE https://secure.rrb.gov/

SECTION 9 Do you have “group insurance” or other health insurance from an employer?

If you (or your spouse) get benefits from your (or your spouse’s) employer or retiree group as

part of this plan, you may call the employer/union benefits administrator or Member Services if

you have any questions. You can ask about your (or your spouse’s) employer or retiree health

benefits or premiums. (Phone numbers for Member Services are printed on the back cover of this

booklet.) You may also call 1-800-MEDICARE (1-800-633-4227; TTY: 1-877-486-2048) with

questions related to your Medicare coverage under this plan or enrollment periods to make a

change.

If you have other prescription drug coverage through your (or your spouse’s) employer or

retiree group, please contact that group’s benefits administrator. The benefits administrator

can help you determine how your current prescription drug coverage will work with our plan.

https://secure.rrb.gov/

CHAPTER 3

Using the plan’s coverage for your medical services


Chapter 3. Using the plan’s coverage for your medical services


SECTION 1 Things to know about getting your medical care covered as a member of our plan ....................................................................... 41

Section 1.1 What are “network providers” and “covered services”? ............................... 41

Section 1.2 Basic rules for getting your medical care covered by the plan ..................... 41

SECTION 2 Use providers in the plan’s network to get your medical care .................................................................................................... 42

Section 2.1 You must choose a Primary Care Provider (PCP) to provide and oversee

your care ........................................................................................................ 42

Section 2.2 What kinds of medical care can you get without getting approval in

advance from your PCP?............................................................................... 44

Section 2.3 How to get care from specialists and other network providers ..................... 44

Section 2.4 How to get care from out-of-network providers ........................................... 46

SECTION 3 How to get covered services when you have an emergency or urgent need for care or during a disaster .................................. 46

Section 3.1 Getting care if you have a medical emergency ............................................. 46

Section 3.2 Getting care when you have an urgent need for services .............................. 47

Section 3.3 Getting care during a disaster ........................................................................ 48

SECTION 4 What if you are billed directly for the full cost of your covered services? ............................................................................ 48

Section 4.1 You can ask us to pay our share of the cost for covered services ................. 48

Section 4.2 What should you do if services are not covered by our plan?....................... 49

SECTION 5 How are your medical services covered when you are in a “clinical research study”? ............................................................... 49

Section 5.1 What is a “clinical research study”? .............................................................. 49

Section 5.2 When you participate in a clinical research study, who pays for what? ....... 50

SECTION 6 Rules for getting care covered in a “religious non-medical health care institution” .................................................................... 51

Section 6.1 What is a religious non-medical health care institution? .............................. 51

Section 6.2 What care from a religious non-medical health care institution is covered

by our plan? ................................................................................................... 51

SECTION 7 Rules for ownership of durable medical equipment ..................... 52

Section 7.1 Will you own the durable medical equipment after making a certain

number of payments under our plan? ............................................................ 52



SECTION 1 Things to know about getting your medical care covered as a member of our plan

This chapter explains what you need to know about using the plan to get your medical care

covered. It gives definitions of terms and explains the rules you will need to follow to get the

medical treatments, services, and other medical care that are covered by the plan.

For the details on what medical care is covered by our plan and how much you pay when you

get this care, use the benefits chart in the next chapter, Chapter 4 (Benefits Chart, what is

covered and what you pay).

Section 1.1 What are “network providers” and “covered services”?

Here are some definitions that can help you understand how you get the care and services that

are covered for you as a member of our plan:

• “Providers” are doctors and other health care professionals licensed by the state to

provide medical services and care. The term “providers” also includes hospitals and other

health care facilities.

• “Network providers” are the doctors and other health care professionals, medical

groups, hospitals, and other health care facilities that have an agreement with us to accept

our payment and your cost-sharing amount as payment in full. We have arranged for

these providers to deliver covered services to members in our plan. The providers in our

network bill us directly for care they give you. When you see a network provider, you

pay only your share of the cost for covered services.

• “Covered services” include all the medical care, health care services, supplies, and

equipment that are covered by our plan. Your covered services for medical care are listed

in the benefits chart in Chapter 4.

Section 1.2 Basic rules for getting your medical care covered by the plan

As a Medicare health plan, MetroPlus Advantage Plan (HMO SNP) must cover all services

covered by Original Medicare.

MetroPlus Advantage Plan (HMO SNP) will generally cover your medical care as long as:

• The care you receive is included in the plan’s Benefits Chart (this chart is in Chapter

4 of this booklet).

• The care you receive is considered medically necessary. “Medically necessary” means

that the services, supplies, or drugs are needed for the prevention, diagnosis, or treatment

of your medical condition and meet accepted standards of medical practice.



• You have a network primary care provider (a PCP) who is providing and

overseeing your care. As a member of our plan, you must choose a network PCP (for

more information about this, see Section 2.1 in this chapter).

o In most situations, your network PCP must give you approval in advance before

you can use other providers in the plan’s network, such as specialists, hospitals,

skilled nursing facilities, or home health care agencies. This is called giving you a

“referral.” For more information about this, see Section 2.3 of this chapter.

o Referrals from your PCP are not required for emergency care or urgently needed

services. There are also some other kinds of care you can get without having

approval in advance from your PCP (for more information about this, see Section

2.2 of this chapter).

• You must receive your care from a network provider (for more information about

this, see Section 2 in this chapter). In most cases, care you receive from an out-of-

network provider (a provider who is not part of our plan’s network) will not be covered.

Here are three exceptions:

o The plan covers emergency care or urgently needed services that you get from an

out-of-network provider. For more information about this, and to see what

emergency or urgently needed services means, see Section 3 in this chapter.

o If you need medical care that Medicare or Medicaid requires our plan to cover and

the providers in our network cannot provide this care, you can get this care from

an out-of-network provider. You are required to obtain authorization from the

plan prior to seeking care from an out-of-network provider. In this situation, we

will cover these services as if you got the care from a network provider. For

information about getting approval to see an out-of-network doctor, see Section

2.4 in this chapter.

o The plan covers kidney dialysis services that you get at a Medicare-certified

dialysis facility when you are temporarily outside the plan’s service area.

SECTION 2 Use providers in the plan’s network to get your medical care

Section 2.1 You must choose a Primary Care Provider (PCP) to provide and oversee your care

What is a “PCP” and what does the PCP do for you?

When you become a member of our Plan, you must choose a plan provider to be your PCP. Your

PCP is a physician or Nurse Practitioner who meets state requirements and is trained to give you

basic medical care.

As we explain below, you will get your routine or basic care from your PCP. Your PCP will also

coordinate the rest of the covered services you get as a member of our Plan. For example, in



order for you to see a specialist, you usually need to consult with your PCP first. Your PCP will

refer you to a specialist. Your PCP will provide most of your care and will help you arrange or

coordinate the rest of the covered services you get as a member of our Plan. This includes:

• Your x-rays

• Laboratory tests

• Therapies

• Care from doctors who are specialists

• Hospital admissions, and

• Follow-up care.

“Coordinating” your services includes checking or consulting with other plan providers about

your care and how it is going. If you need certain types of covered services or supplies, you must

get approval in advance from your PCP. In some cases, your PCP will need to get prior

authorization (prior approval) from us. Since your PCP will provide and coordinate your medical

care, you should have all of your past medical records sent to your PCP’s office.

How do you choose your PCP?

You may have already picked your PCP to serve as your regular doctor. This person could be a

doctor or a nurse practitioner. You may choose a PCP by using our Provider/Pharmacy Directory

that lists the address, phone number, and special training of the doctors. You should call your

PCP’s office to make sure she/he takes new patients. Once you choose a PCP, please call our

Member Services Department so that we can update our records. If you have not chosen a PCP,

you should do so right away. If you do not choose a PCP within 30 days from the date you

become a member of our plan, we will choose one for you.

Changing your PCP

You may change your PCP for any reason, at any time. Also, it’s possible that your PCP might

leave our plan’s network of providers and you would have to find a new PCP.

Please call our Member Services Department and we can help you choose a new PCP. If you call

us to change your PCP on or before the 15th of the month, your PCP change will be effective as

of the first of that month. If you call us after the 15th of the month, it will be effective as of the

first of the next month.

If your PCP leaves our network, you may be able to continue seeing them for a transitional

period of time (90 days). You or your PCP must contact Member Services in advance to arrange

this.



Section 2.2 What kinds of medical care can you get without getting approval in advance from your PCP?

You can get the services listed below without getting approval in advance from your PCP.

• Routine women’s health care, which includes breast exams, screening mammograms (x-

rays of the breast), Pap tests, and pelvic exams as long as you get them from a network

provider

• Flu shots and pneumonia vaccinations as long as you get them from a network provider

• Emergency services from network providers or from out-of-network providers

• Urgently needed services from network providers or from out-of-network providers when

network providers are temporarily unavailable or inaccessible, e.g., when you are

temporarily outside of the plan’s service area

Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are

temporarily outside the plan’s service area. (If possible, please call Member Services before you

leave the service area so we can help arrange for you to have maintenance dialysis while you are

away. Phone numbers for Member Services are printed on the back cover of this booklet.)

Section 2.3 How to get care from specialists and other network providers

A specialist is a doctor who provides health care services for a specific disease or part of the

body. There are many kinds of specialists. Here are a few examples:

• Oncologists care for patients with cancer

• Cardiologists care for patients with heart conditions

• Orthopedists care for patients with certain bone, joint, or muscle conditions

There are some medical services that require permission from MetroPlus Health Plan in order for

the Plan to pay for these services. Please see Chapter 4, Section 2.1 for information about which

services require prior authorizations or prior approvals. In general, the health care provider who

orders the service will arrange to obtain the Prior Authorization from the plan. In order to

approve the request the health care provider will provide the Plan with medical information to

explain your need for the service being requested. In an emergency, the physician/hospital must

notify us as soon as possible. Briefly, the following services require Prior Authorization from the

Plan.

• All service by Out of Network providers including physicians, hospitals, DME vendors

and other Out of Network providers

• All inpatient hospital admissions (medical, surgical, acute rehabilitation, sub- acute

rehabilitation, skilled nursing facility, inpatient drug or alcohol admissions or psychiatric

inpatient admissions)



• Planned or elective hospital admissions must be authorized no later than 7 days prior to

the anticipated date of admission.

• All durable medical equipment must be Prior Authorized. In this case, either the

physician ordering the equipment or the company providing the equipment will obtain the

Prior Authorization

• All home care services covered by the Plan must also be Prior Authorized. Again the

health care provider ordering these services will generally obtain the Prior Authorization.

Sometimes the agency that provides the home care services will obtain the prior

authorization.

• Special x-ray procedures such as outpatient CT scans (computerized tomography), PET

scans (Positron Emission Tomography), MRI scans (Magnetic Resonance Imaging) or

other high technology x-ray tests must also receive prior authorization from our radiology

vendor. The ordering physician/provider should contact our radiology vendor for

additional information

Once a request for a Prior Authorization is received by MetroPlus Health Plan, one of the Plan’s

Medical Directors will review the request to determine whether the service requested is

medically necessary and a covered benefit. In some cases, such as special x-ray tests noted

above, MetroPlus will have a special outside physician review the request and make the decision

regarding the test.

What if a specialist or another network provider leaves our plan?

We may make changes to the hospitals, doctors, and specialists (providers) that are part of your

plan during the year. There are a number of reasons why your provider might leave your plan,

but if your doctor or specialist does leave your plan you have certain rights and protections that

are summarized below:

• Even though our network of providers may change during the year, Medicare requires

that we furnish you with uninterrupted access to qualified doctors and specialists.

• We will make a good faith effort to provide you with at least 30 days’ notice that your

provider is leaving our plan so that you have time to select a new provider.

• We will assist you in selecting a new qualified provider to continue managing your health

care needs.

• If you are undergoing medical treatment you have the right to request, and we will work

with you to ensure, that the medically necessary treatment you are receiving is not

interrupted.

• If you believe we have not furnished you with a qualified provider to replace your

previous provider or that your care is not being appropriately managed, you have the

right to file an appeal of our decision.

• If you find out your doctor or specialist is leaving your plan, please contact us so we can

assist you in finding a new provider and managing your care.



For assistance with changing your specialist or network provider, please call Member Services

(phone numbers are located on the back of this booklet).

Section 2.4 How to get care from out-of-network providers

If we do not have a specialist in MetroPlus Health Plan who can give you the care you need, we

will get you the care you need from a specialist outside the network. Before you can see the

specialist, your doctor must ask MetroPlus for a referral.

To get the referral, your doctor must give us some information. Once we get all this information,

we will decide within 14 calendar days from the date of your request if you can see the out-of-

network specialist. You or your doctor can ask for a fast track review if your doctor feels that a

delay will cause serious harm to your health. In that case, we will decide and get back to you in

72 hours.

SECTION 3 How to get covered services when you have an emergency or urgent need for care or during a disaster

Section 3.1 Getting care if you have a medical emergency

What is a “medical emergency” and what should you do if you have one?

A “medical emergency” is when you, or any other prudent layperson with an average

knowledge of health and medicine, believe that you have medical symptoms that require

immediate medical attention to prevent loss of life, loss of a limb, or loss of function of a limb.

The medical symptoms may be an illness, injury, severe pain, or a medical condition that is

quickly getting worse.

If you have a medical emergency:

• Get help as quickly as possible. Call 911 for help or go to the nearest emergency room

or hospital. Call for an ambulance if you need it. You do not need to get approval or a

referral first from your PCP.

• As soon as possible, make sure that our plan has been told about your emergency.

We need to follow up on your emergency care. You or someone else should call to tell us

about your emergency care, usually within 48 hours. Please call your PCP at the office

number located on your Member ID card. Your PCP will help manage and follow up on

your emergency care.



What is covered if you have a medical emergency?

You may get covered emergency medical care whenever you need it, anywhere in the United

States or its territories. Our plan covers ambulance services in situations where getting to the

emergency room in any other way could endanger your health. For more information, see the

Benefits Chart in Chapter 4 of this booklet.

If you have an emergency, we will talk with the doctors who are giving you emergency care to

help manage and follow up on your care. The doctors who are giving you emergency care will

decide when your condition is stable and the medical emergency is over.

After the emergency is over you are entitled to follow-up care to be sure your condition

continues to be stable. Your follow-up care will be covered by our plan. If your emergency care

is provided by out-of-network providers, we will try to arrange for network providers to take

over your care as soon as your medical condition and the circumstances allow.

What if it wasn’t a medical emergency?

Sometimes it can be hard to know if you have a medical emergency. For example, you might go

in for emergency care – thinking that your health is in serious danger – and the doctor may say

that it wasn’t a medical emergency after all. If it turns out that it was not an emergency, as long as you reasonably thought your health was in serious danger, we will cover your care.

However, after the doctor has said that it was not an emergency, we will cover additional care

only if you get the additional care in one of these two ways:

• You go to a network provider to get the additional care.

• – or – The additional care you get is considered “urgently needed services” and you follow the rules for getting this urgent care (for more information about this, see Section

3.2 below).

Section 3.2 Getting care when you have an urgent need for services

What are “urgently needed services”?

“Urgently needed services” are non-emergency, unforeseen medical illness, injury, or condition

that requires immediate medical care. Urgently needed services may be furnished by network

providers or by out-of-network providers when network providers are temporarily unavailable or

inaccessible. The unforeseen condition could, for example, be an unforeseen flare-up of a known

condition that you have.

What if you are in the plan’s service area when you have an urgent need for care?

You should always try to obtain urgently needed services from network providers. However, if

providers are temporarily unavailable or inaccessible and it is not reasonable to wait to obtain



care from your network provider when the network becomes available, we will cover urgently

needed services that you get from an out-of-network provider.

To access urgently needed services, you can visit an Urgent Care facility. You can find a list of

participating Urgent Care facilities in your Provider/Pharmacy Directory, or on our website. You

can also contact your PCP or Member Services for help arranging care.

What if you are outside the plan’s service area when you have an urgent need for care?

When you are outside the service area and cannot get care from a network provider, our plan will

cover urgently needed services that you get from any provider.

Our plan does not cover urgently needed services or any other care if you receive the care

outside of the United States. Medicaid does not cover any services outside of the United States or

its territories.

Section 3.3 Getting care during a disaster

If the Governor of your state, the U.S. Secretary of Health and Human Services, or the President

of the United States declares a state of disaster or emergency in your geographic area, you are

still entitled to care from your plan.

Please visit the following website: www.metroplus.org for information on how to obtain needed

care during a disaster.

Generally, if you cannot use a network provider during a disaster, your plan will allow you to

obtain care from out-of-network providers at in-network cost-sharing. If you cannot use a

network pharmacy during a disaster, you may be able to fill your prescription drugs at an out-of-

network pharmacy. Please see Chapter 5, Section 2.5 for more information.

SECTION 4 What if you are billed directly for the full cost of your covered services?

Section 4.1 You can ask us to pay our share of the cost for covered services

If you have paid more than your share for covered services, or if you have received a bill for the

full cost of covered medical services, go to Chapter 7 (Asking us to pay our share of a bill you

have received for covered medical services or drugs) for information about what to do.

www.metroplus.org



Section 4.2 What should you do if services are not covered by our plan?

Before paying for the cost of the service, you should check if the service is covered by Medicaid.

MetroPlus Advantage Plan (HMO SNP) covers all medical services that are medically necessary,

are listed in the plan’s Benefits Chart (this chart is in Chapter 4 of this booklet), and are obtained

consistent with plan rules. You are responsible for paying the full cost of services that aren’t

covered by our plan, either because they are not plan covered services, or they were obtained

out-of-network and were not authorized.

If you have any questions about whether we will pay for any medical service or care that you are

considering, you have the right to ask us whether we will cover it before you get it. You also

have the right to ask for this in writing. If we say we will not cover your services, you have the

right to appeal our decision not to cover your care.

Chapter 9 (What to do if you have a problem or complaint (coverage decisions, appeals,

complaints)) has more information about what to do if you want a coverage decision from us or

want to appeal a decision we have already made. You may also call Member Services to get

more information (phone numbers are printed on the back cover of this booklet).

For covered services that have a benefit limitation, you pay the full cost of any services you get

after you have used up your benefit for that type of covered service. These costs will not count

towards your out-of-pocket maximum. You can call Member Services when you want to know

how much of your benefit limit you have already used.

SECTION 5 How are your medical services covered when you are in a “clinical research study”?

Section 5.1 What is a “clinical research study”?

A clinical research study (also called a “clinical trial”) is a way that doctors and scientists test

new types of medical care, like how well a new cancer drug works. They test new medical care

procedures or drugs by asking for volunteers to help with the study. This kind of study is one of

the final stages of a research process that helps doctors and scientists see if a new approach

works and if it is safe.

Not all clinical research studies are open to members of our plan. Medicare first needs to approve

the research study. If you participate in a study that Medicare has not approved, you will be

responsible for paying all costs for your participation in the study.

Once Medicare approves the study, someone who works on the study will contact you to explain

more about the study and see if you meet the requirements set by the scientists who are running

the study. You can participate in the study as long as you meet the requirements for the study and

you have a full understanding and acceptance of what is involved if you participate in the study.



If you participate in a Medicare-approved study, Original Medicare pays most of the costs for the

covered services you receive as part of the study. When you are in a clinical research study, you

may stay enrolled in our plan and continue to get the rest of your care (the care that is not related

to the study) through our plan.

If you want to participate in a Medicare-approved clinical research study, you do not need to get

approval from us or your PCP. The providers that deliver your care as part of the clinical

research study do not need to be part of our plan’s network of providers.

Although you do not need to get our plan’s permission to be in a clinical research study, you do

need to tell us before you start participating in a clinical research study.

If you plan on participating in a clinical research study, contact Member Services (phone

numbers are printed on the back cover of this booklet) to let them know that you will be

participating in a clinical trial and to find out more specific details about what your plan will pay.

Section 5.2 When you participate in a clinical research study, who pays for what?

Once you join a Medicare-approved clinical research study, you are covered for routine items

and services you receive as part of the study, including:

• Room and board for a hospital stay that Medicare would pay for even if you weren’t in a study

• An operation or other medical procedure if it is part of the research study

• Treatment of side effects and complications of the new care

Original Medicare pays most of the cost of the covered services you receive as part of the study.

After Medicare has paid its share of the cost for these services, our plan will also pay for part of

the costs. We will pay the difference between the cost-sharing in Original Medicare and your

cost-sharing as a member of our plan. This means you will pay the same amount for the services

you receive as part of the study as you would if you received these services from our plan.

Here’s an example of how the cost-sharing works: Let’s say that you have a lab test that

costs $100 as part of the research study. Let’s also say that your share of the costs for this

test is $20 under Original Medicare, but the test would be $10 under our plan’s benefits.

In this case, Original Medicare would pay $80 for the test and we would pay another $10.

This means that you would pay $10, which is the same amount you would pay under our

plan’s benefits.

In order for us to pay for our share of the costs, you will need to submit a request for payment.

With your request, you will need to send us a copy of your Medicare Summary Notices or other

documentation that shows what services you received as part of the and how much you owe.

Please see Chapter 7 for more information about submitting requests for payment.



When you are part of a clinical research study, neither Medicare nor our plan will pay for any

of the following:

• Generally, Medicare will not pay for the new item or service that the study is testing

unless Medicare would cover the item or service even if you were not in a study.

• Items and services the study gives you or any participant for free

• Items or services provided only to collect data, and not used in your direct health care.

For example, Medicare would not pay for monthly CT scans done as part of the study if

your medical condition would normally require only one CT scan.

Do you want to know more?

You can get more information about joining a clinical research study by reading the publication

“Medicare and Clinical Research Studies” on the Medicare website (https://www.medicare.gov).

You can also call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY

users should call 1-877-486-2048.

SECTION 6 Rules for getting care covered in a “religious non-medical health care institution”

Section 6.1 What is a religious non-medical health care institution?

A religious non-medical health care institution is a facility that provides care for a condition that

would ordinarily be treated in a hospital or skilled nursing facility. If getting care in a hospital or

a skilled nursing facility is against a member’s religious beliefs, we will instead provide

coverage for care in a religious non-medical health care institution. You may choose to pursue

medical care at any time for any reason. This benefit is provided only for Part A inpatient

services (non-medical health care services). Medicare will only pay for non-medical health care

services provided by religious non-medical health care institutions.

Section 6.2 What care from a religious non-medical health care institution is covered by our plan?

To get care from a religious non-medical health care institution, you must sign a legal document

that says you are conscientiously opposed to getting medical treatment that is “non-excepted.”

• “Non-excepted” medical care or treatment is any medical care or treatment that is voluntary and not required by any federal, state, or local law.

• “Excepted” medical treatment is medical care or treatment that you get that is not

voluntary or is required under federal, state, or local law.




To be covered by our plan, the care you get from a religious non-medical health care institution

must meet the following conditions:

• The facility providing the care must be certified by Medicare.

• Our plan’s coverage of services you receive is limited to non-religious aspects of care.

• If you get services from this institution that are provided to you in a facility, the

following conditions apply:

o You must have a medical condition that would allow you to receive covered

services for inpatient hospital care or skilled nursing facility care.

o – and – You must get approval in advance from our plan before you are admitted

to the facility or your stay will not be covered.

Your stay in the RNHCI is not covered by our plan unless you obtain authorization (approval) in

advance from our Plan. Medicare Inpatient Hospital Coverage limits apply. These limits are

described in the Benefits Chart in Chapter 4.

SECTION 7 Rules for ownership of durable medical equipment

Section 7.1 Will you own the durable medical equipment after making a certain number of payments under our plan?

Durable medical equipment (DME) includes items such as oxygen equipment and supplies,

wheelchairs, walkers, powered mattress systems, crutches, diabetic supplies, speech generating

devices, IV infusion pumps, nebulizers, and hospital beds ordered by a provider for use in the

home. The member always owns certain items, such as prosthetics. In this section, we discuss

other types of DME that you must rent.

In Original Medicare, people who rent certain types of DME own the equipment after paying

copayments for the item for 13 months. As a member of MetroPlus Advantage Plan (HMO

SNP), however, you usually will not acquire ownership of rented DME items no matter how

many copayments you make for the item while a member of our plan. Under certain limited

circumstances we will transfer ownership of the DME item to you. Call Member Services (phone

numbers are printed on the back cover of this booklet) to find out about the requirements you

must meet and the documentation you need to provide.

What happens to payments you made for durable medical equipment if you switch to Original Medicare?

If you did not acquire ownership of the DME item while in our plan, you will have to make 13

new consecutive payments after you switch to Original Medicare in order to own the item.

Payments you made while in our plan do not count toward these 13 consecutive payments.



If you made fewer than 13 payments for the DME item under Original Medicare before you

joined our plan, your previous payments also do not count toward the 13 consecutive payments.

You will have to make 13 new consecutive payments after you return to Original Medicare in

order to own the item. There are no exceptions to this case when you return to Original

Medicare.

CHAPTER 4

Benefits Chart (what is covered and what you pay)


Chapter 4. Benefits Chart (what is covered and what you pay)


SECTION 1 Understanding your out-of-pocket costs for covered services ............................................................................................. 56

Section 1.1 Types of out-of-pocket costs you may pay for your covered services .......... 56

Section 1.2 What is your plan deductible? ....................................................................... 56

Section 1.3 What is the most you will pay for covered medical services? ...................... 57

Section 1.4 Our plan does not allow providers to “balance bill” you .............................. 57

SECTION 2 Use the Benefits Chart to find out what is covered for you and how much you will pay ............................................................. 58

Section 2.1 Your medical benefits and costs as a member of the plan ............................ 58

SECTION 3 What services are covered outside of MetroPlus Advantage Plan (HMO SNP)?.............................................................................. 87

Section 3.1 Services not covered by MetroPlus Advantage Plan (HMO SNP) ............... 87

SECTION 4 What services are not covered by the plan?................................ 100

Section 4.1 Services not covered by the plan (exclusions) ............................................ 100



SECTION 1 Understanding your out-of-pocket costs for covered services

This chapter focuses on what services are covered and what you pay for these services. It includes

a Benefits Chart that lists your covered services and shows how much you will pay for each

covered service as a member of MetroPlus Advantage Plan (HMO SNP). Later in this chapter,

you can find information about medical services that are not covered. It also explains limits on

certain services.

Section 1.1 Types of out-of-pocket costs you may pay for your covered services

To understand the payment information we give you in this chapter, you need to know about the

types of out-of-pocket costs you may pay for your covered services.

• The “deductible” is the amount you must pay for medical services before our plan begins

to pay its share. (Section 1.2 tells you more about your plan deductible.)

• A “copayment” is the fixed amount you pay each time you receive certain medical

services. You pay a copayment at the time you get the medical service. (The Benefits

Chart in Section 2 tells you more about your copayments.)

• “Coinsurance” is the percentage you pay of the total cost of certain medical services.

You pay a coinsurance at the time you get the medical service. (The Benefits Chart in

Section 2 tells you more about your coinsurance.)

Section 1.2 What is your plan deductible?

Your deductible is $0 or $185. This is the amount you have to pay out-of-pocket before we will

pay our share for your covered medical services. Until you have paid the deductible amount, you

must pay the full cost of your covered services. Once you have paid your deductible, we will

begin to pay our share of the costs for covered medical services and you will pay your share

(your copayment or coinsurance amount) for the rest of the calendar year.

The deductible does not apply to some services. This means that we will pay our share of the

costs for these services even if you haven’t paid your deductible yet. The deductible does not apply to the following services:

• Home Health Care

• Medicare-covered preventative services (such as kidney disease education, glaucoma

screening, diabetes self-management training, and other items indicated as preventative in

the Benefits Chart)

If you are eligible for Medicare cost-sharing assistance under Medicaid, you have no deductible.



Section 1.3 What is the most you will pay for covered medical services?

Note: Because our members also get assistance from Medicaid, very few members ever reach

this out-of-pocket maximum. If you are eligible for Medicare cost-sharing assistance under

Medicaid, you are not responsible for paying any out-of-pocket costs toward the maximum out-

of-pocket amount for covered Part A and Part B services.

Because you are enrolled in a Medicare Advantage Plan, there is a limit to how much you have

to pay out-of-pocket each year for medical services that are covered by our plan (see the Medical

Benefits Chart in Section 2, below). This limit is called the maximum out-of-pocket amount for

medical services.

As a member of MetroPlus Advantage Plan (HMO SNP), the most you will have to pay out-of-

pocket for services in 2019 is $6,700. The amounts you pay for deductibles, copayments, and

coinsurance for covered services count toward this maximum out-of-pocket amount. (The

amounts you pay for your plan premiums and for your Part D prescription drugs do not count

toward your maximum out-of-pocket amount.) If you reach the maximum out-of-pocket amount

of $6,700, you will not have to pay any out-of-pocket costs for the rest of the year for covered

services. However, you must continue to pay your plan premium and the Medicare Part B

premium (unless your Part B premium is paid for you by Medicaid or another third party).

Section 1.4 Our plan does not allow providers to “balance bill” you

As a member of MetroPlus Advantage Plan (HMO SNP), an important protection for you is that

after you meet any deductibles, you only have to pay your cost-sharing amount when you get

services covered by our plan. We do not allow providers to add additional separate charges,

called “balance billing.” This protection (that you never pay more than your cost-sharing

amount) applies even if we pay the provider less than the provider charges for a service and even

if there is a dispute and we don’t pay certain provider charges.

Here is how this protection works.

• If your cost-sharing is a copayment (a set amount of dollars, for example, $15.00), then

you pay only that amount for any covered services from a network provider.

• If your cost-sharing is a coinsurance (a percentage of the total charges), then you never

pay more than that percentage. However, your cost depends on which type of provider

you see:

o If you receive the covered services from a network provider, you pay the

coinsurance percentage multiplied by the plan’s reimbursement rate (as

determined in the contract between the provider and the plan).

o If you receive the covered services from an out-of-network provider who

participates with Medicare, you pay the coinsurance percentage multiplied by the

Medicare payment rate for participating providers. (Remember, the plan covers

services from out-of-network providers only in certain situations, such as when

you get a referral.)



o If you receive the covered services from an out-of-network provider who does not

participate with Medicare, you pay the coinsurance percentage multiplied by the

Medicare payment rate for non-participating providers. (Remember, the plan

covers services from out-of-network providers only in certain situations, such as

when you get a referral.)

• If you believe a provider has “balance billed” you, call Member Services (phone numbers

are printed on the back cover of this booklet).

We do not allow providers to bill you for covered services. We pay our providers directly, and

we protect you from any charges. This is true even if we pay the provider less than the provider

charges for a service. If you receive a bill from a provider, call Member Services (phone


SECTION 2 Use the Benefits Chart to find out what is covered for you and how much you will pay

Section 2.1 Your medical benefits and costs as a member of the plan

The Benefits Chart on the following pages lists the services MetroPlus Advantage Plan (HMO

SNP) covered and what you pay out-of-pocket for each service. The services listed in the

Benefits Chart are covered only when the following coverage requirements are met:

• Your Medicare covered services must be provided according to the coverage guidelines

established by Medicare.

• Your services (including medical care, services, supplies, and equipment) must be

medically necessary. “Medically necessary” means that the services, supplies, or drugs

are needed for the prevention, diagnosis, or treatment of your medical condition and

meet accepted standards of medical practice.

• You receive your care from a network provider. In most cases, care you receive from an

out-of-network provider will not be covered. Chapter 3 provides more information about

requirements for using network providers and the situations when we will cover services

from an out-of-network provider.

• You have a primary care provider (a PCP) who is providing and overseeing your care. In

most situations, your PCP must give you approval in advance before you can see other

providers in the plan’s network. This is called giving you a “referral.” Chapter 3

provides more information about getting a referral and the situations when you do not

need a referral.

• Some of the services listed in the Benefits Chart are covered only if your doctor or other

network provider gets approval in advance (sometimes called “prior authorization”) from

us. Covered services that need approval in advance are marked in the Benefits Chart by

an asterisk.



Other important things to know about our coverage:

• You are covered by both Medicare and Medicaid. Medicare covers health care and

prescription drugs. Medicaid covers your cost-sharing for Medicare services. Medicaid

also covers services Medicare does not cover.

• Like all Medicare health plans, we cover everything that Original Medicare covers. (If

you want to know more about the coverage and costs of Original Medicare, look in your

Medicare & You 2019 Handbook. View it online at https://www.medicare.gov or ask for

a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week.

TTY users should call 1-877-486-2048.)

• For all preventive services that are covered at no cost under Original Medicare, we also

cover the service at no cost to you. However, if you also are treated or monitored for an

existing medical condition during the visit when you receive the preventive service, a

copayment will apply for the care received for the existing medical condition.

• Sometimes, Medicare adds coverage under Original Medicare for new services during the

year. If Medicare adds coverage for any services during 2019, either Medicare or our plan

will cover those services.

• If you are within our plan’s 90 day period of deemed continued eligibility, we will

continue to provide all Medicare Advantage plan-covered Medicare benefits. However,

during this period, your Medicaid benefits provided by New York State might not be

available to you. Please contact NY Medicaid CHOICE Helpline at 1-800-505-5678.

Medicare cost sharing amounts for Medicare basic and supplemental benefits do not

change during this period.

If you are eligible for Medicare cost-sharing assistance under Medicaid, you do not pay

anything for the services listed in the Benefits Chart, as long as you meet the coverage

requirements described above.

You will see this apple next to the preventive services in the benefits chart.




Benefits Chart

Services that are covered for you

Abdominal aortic aneurysm screening

A one-time screening ultrasound for people at risk. The plan

only covers this screening if you have certain risk factors and if

you get a referral for it from your physician, physician assistant,

nurse practitioner, or clinical nurse specialist.

What you must pay when

you get these services

There is no coinsurance,

copayment, or deductible

for members eligible for

this preventive screening.

Ambulance services

• Covered ambulance services include fixed wing, rotary

wing, and ground ambulance services, to the nearest

appropriate facility that can provide care only if they are

furnished to a member whose medical condition is such that

other means of transportation could endanger the person’s

health or if authorized by the plan.

• Non-emergency transportation by ambulance is appropriate

if it is documented that the member’s condition is such that

other means of transportation could endanger the person’s

health and that transportation by ambulance is medically

required.*

Depending on your level of

income and Medicaid

eligibility, you pay 0% or

20% coinsurance

Prior authorization required

for non-emergency

services.

Annual wellness visit

If you’ve had Part B for longer than 12 months, you can get an

annual wellness visit to develop or update a personalized

prevention plan based on your current health and risk factors.

This is covered once every 12 months.

Note: Your first annual wellness visit can’t take place within 12

months of your “Welcome to Medicare” preventive visit.

However, you don’t need to have had a “Welcome to

Medicare” visit to be covered for annual wellness visits after

you’ve had Part B for 12 months.



for the annual wellness

visit.

Bone mass measurement

For qualified individuals (generally, this means people at risk of

losing bone mass or at risk of osteoporosis), the following

services are covered every 24 months or more frequently if

medically necessary: procedures to identify bone mass, detect

bone loss, or determine bone quality, including a physician’s interpretation of the results.



for Medicare-covered bone

mass measurement.




Breast cancer screening (mammograms)

Covered services include:

• One baseline mammogram between the ages of 35 and 39

• One screening mammogram every 12 months for women

age 40 and older

• Clinical breast exams once every 24 months





for covered screening

mammograms.

Cardiac rehabilitation services*

Comprehensive programs of cardiac rehabilitation services that

include exercise, education, and counseling are covered for

members who meet certain conditions with a doctor’s referral.

The plan also covers intensive cardiac rehabilitation programs

that are typically more rigorous or more intense than cardiac

rehabilitation programs.


income and Medicaid


20% coinsurance

Prior authorization

required.

Cardiovascular disease risk reduction visit (therapy for

cardiovascular disease)

We cover one visit per year with your primary care doctor to

help lower your risk for cardiovascular disease. During this

visit, your doctor may discuss aspirin use (if appropriate),

check your blood pressure, and give you tips to make sure

you’re eating healthy.



for the intensive behavioral

therapy cardiovascular

disease preventive benefit.

Cardiovascular disease testing

Blood tests for the detection of cardiovascular disease (or

abnormalities associated with an elevated risk of cardiovascular

disease) once every 5 years (60 months)



for cardiovascular disease

testing that is covered once

every 5 years.

Cervical and vaginal cancer screening


• For all women: Pap tests and pelvic exams are covered once

every 24 months

• If you are at high risk of cervical or vaginal cancer or you

are of childbearing age and have had an abnormal Pap test

within the past 3 years: one Pap test every 12 months



for Medicare-covered

preventive Pap and pelvic

exams.




Chiropractic services*


• Manual manipulation of the spine to correct subluxation




income and Medicaid


20% coinsurance

Prior authorization

required.

Colorectal cancer screening

For people 50 and older, the following are covered:

• Flexible sigmoidoscopy (or screening barium enema as an

alternative) every 48 months

One of the following every 12 months:

• Guaiac-based fecal occult blood test (gFOBT)

• Fecal immunochemical test (FIT)

DNA based colorectal screening every 3 years

For people at high risk of colorectal cancer, we cover:

• Screening colonoscopy (or screening barium enema as an

alternative) every 24 months

For people not at high risk of colorectal cancer, we cover:

• Screening colonoscopy every 10 years (120 months), but

not within 48 months of a screening sigmoidoscopy



for a Medicare-covered

colorectal cancer screening

exam.

Barium enema: Depending

on your level of income

and Medicaid eligibility,

you pay 0% or 20%

coinsurance

Dental services

In general, preventive dental services (such as cleaning, routine

dental exams, and dental x-rays) are not covered by Original

Medicare. We cover:

• Otherwise non-covered procedure or service (e.g., tooth

removal) if performed by a dentist incident to and as an

integral part of an otherwise covered procedure, then the

total service performed by the dentist is covered.

• Extractions of teeth to prepare jaw for radiation

treatment of neoplastic disease.

• Dental exams prior to kidney transplantation.


income and Medicaid


20% coinsurance




Services that are covered for you you get these services

Comprehensive Dental Services*

Restorative and Prosthodontics:

• Crowns-single restoration and fixed partial denture

retainer crowns selected types shown below only:

o Resin based composite (indirect)

o Resin with noble, or high noble metal

o Resin with predominantly base metal

o Porcelain/ceramic

o Porcelain fused to noble or high noble metal

o Porcelain fused to predominantly base metal

o Full cast noble or high noble metal

o Full cast predominantly base metal

• Fixed partial denture pontics selected types shown

below only:

o Resin with noble, or high noble metal

o Resin with predominantly base metal

o Porcelain fused to noble or high noble metal

o Porcelain fused to predominantly base metal

o Cast noble or high noble metal

o Cast predominantly base metal

• Major restoratives selected types shown below only:

o Post and core in addition to crown, indirectly

fabricated

o Each additional indirectly fabricated post same

tooth

o Prefabricated post and core in addition to crown

Endodontics limited to root canal therapy - selected

services shown below only:

• Endodontic therapy - molar tooth (excluding final

restoration)

• Retreatment of previous root canal therapy - molar tooth

Periodontics limited to osseous surgery including

elevation of a full thickness flap and closure

Maximum annual plan benefit coverage amount of $1,000

Restorative and

Prosthodontics: $0

copayment

Limited to 1 every 60

months, per tooth.

Endodontics: $0

copayment

Limited to 1 per lifetime,

per tooth

Periodontics: $0

copayment

Limited to 1 every 60

months, per quad

Prior authorization

required.




Depression screening

We cover one screening for depression per year. The screening

must be done in a primary care setting that can provide follow-

up treatment and/or referrals.





for an annual depression

screening visit.

Diabetes screening

We cover this screening (includes fasting glucose tests) if you

have any of the following risk factors: high blood pressure

(hypertension), history of abnormal cholesterol and triglyceride

levels (dyslipidemia), obesity, or a history of high blood sugar

(glucose). Tests may also be covered if you meet other

requirements, like being overweight and having a family

history of diabetes.

Based on the results of these tests, you may be eligible for up to

two diabetes screenings every 12 months.



for the Medicare covered

diabetes screening tests.

Diabetes self-management training, diabetic services

and supplies

For all people who have diabetes (insulin and non-insulin

users). Covered services include:

• Supplies to monitor your blood glucose: Blood glucose

monitor, blood glucose test strips, lancet devices and

lancets, and glucose-control solutions for checking the

accuracy of test strips and monitors

• For people with diabetes who have severe diabetic foot

disease: One pair per calendar year of therapeutic custom-

molded shoes (including inserts provided with such shoes)

and two additional pairs of inserts, or one pair of depth

shoes and three pairs of inserts (not including the non-

customized removable inserts provided with such shoes).

Coverage includes fitting.

• Diabetes self-management training is covered under certain

condition


income and Medicaid


20% coinsurance

You must use Abbott

diabetic test strips or

Ascensia diabetic test

strips. If you have a

medical reason to use

another brand of test strips,

your provider must contact

Member Services.





Durable medical equipment (DME) and related supplies*

(For a definition of “durable medical equipment,” see Chapter 12 of this booklet.)

Covered items include, but are not limited to: wheelchairs,

crutches, powered mattress systems, diabetic supplies, hospital

beds ordered by a provider for use in the home, IV infusion

pumps, speech generating devices, oxygen equipment,

nebulizers, and walkers.

With this Evidence of Coverage document, we sent you

MetroPlus Advantage Plan (HMO SNP)’s list of DME. The list

tells you the brands and manufacturers of DME that we will

cover. This most recent list of brands, manufacturers, and

suppliers is also available on our website at

www.metroplusmedicare.org.

Generally, MetroPlus Advantage Plan (HMO SNP) covers any

DME covered by Original Medicare from the brands and

manufacturers on this list. We will not cover other brands and

manufacturers unless your doctor or other provider tells us that

the brand is appropriate for your medical needs. However, if

you are new to MetroPlus Advantage Plan (HMO SNP) and are

using a brand of DME that is not on our list, we will continue to

cover this brand for you for up to 90 days. During this time,

you should talk with your doctor to decide what brand is

medically appropriate for you after this 90-day period. (If you

disagree with your doctor, you can ask him or her to refer you

for a second opinion.)

If you (or your provider) don’t agree with the plan’s coverage decision, you or your provider may file an appeal. You can also

file an appeal if you don’t agree with your provider’s decision

about what product or brand is appropriate for your medical

condition. (For more information about appeals, see Chapter 9,

What to do if you have a problem or complaint (coverage

decisions, appeals, complaints).)


income and Medicaid


20% coinsurance

Prior authorization

required.






Emergency care

Emergency care refers to services that are:

• Furnished by a provider qualified to furnish emergency

services, and

• Needed to evaluate or stabilize an emergency medical

condition.

A medical emergency is when you, or any other prudent

layperson with an average knowledge of health and medicine,

believe that you have medical symptoms that require immediate

medical attention to prevent loss of life, loss of a limb, or loss

of function of a limb. The medical symptoms may be an illness,

injury, severe pain, or a medical condition that is quickly

getting worse.

Cost sharing for necessary emergency services furnished out-

of-network is the same as for such services furnished in-

network.

This coverage is only covered within the U.S.


income and Medicaid


20% coinsurance (up to

$90)

If you are admitted to the

hospital within 3 days, you

do not have to pay your

share of the cost for

emergency care.

If you receive emergency

care at an out-of-network

hospital and need inpatient

care after your emergency

condition is stabilized, you

must return to a network

hospital in order for your

care to continue to be

covered or you must have

your inpatient care at the

out-of-network hospital

authorized by the plan and

your cost is the cost-

sharing you would pay at a

network hospital.

Hearing services

Diagnostic hearing and balance evaluations performed by your

provider to determine if you need medical treatment are

covered as outpatient care when furnished by a physician,

audiologist, or other qualified provider. We cover an exam to

diagnose and treat hearing and balance issues.


income and Medicaid


20% coinsurance





HIV screening

For people who ask for an HIV screening test or who are at

increased risk for HIV infection, we cover:

• One screening exam every 12 months

For women who are pregnant, we cover:

• Up to three screening exams during a pregnancy




Medicare-covered

preventive HIV screening.

Home health agency care* You pay nothing.

Prior to receiving home health services, a doctor must certify

that you need home health services and will order home health Prior authorization

services to be provided by a home health agency. You must be required.

homebound, which means leaving home is a major effort.

Covered services include, but are not limited to:

• Part-time or intermittent skilled nursing and home health

aide services (To be covered under the home health care

benefit, your skilled nursing and home health aide services

combined must total fewer than 8 hours per day and 35

hours per week)

• Physical therapy, occupational therapy, and speech therapy

• Medical and social services

• Medical equipment and supplies





Hospice care

You may receive care from any Medicare-certified hospice

program. our

doctor and the hospice medical director have given you a

terminal prognosis certifying that you’re terminally ill and

have 6 months or less to live if your illness runs its normal

course. Your hospice doctor can be a network provider or an

out-of-network provider. Covered services include:

• Drugs for symptom control and pain relief

• Short-term respite care

• Home care

For hospice services and for services that are covered by

Medicare Part A or B and are related to your terminal

prognosis: Original Medicare (rather than our plan) will pay for

your hospice services related to your terminal prognosis. While

you are in the hospice program, your hospice provider will bill

Original Medicare for the services that Original Medicare pays

for.

When you enroll in a

Medicare-certified hospice

program, your hospice

services and your Part A

and Part B services related

to your terminal prognosis

are paid for by Original

Medicare, not MetroPlus

Advantage Plan (HMO

SNP).





Hospice care (continued)

For services that are covered by Medicare Part A or B and are

not related to your terminal prognosis: If you need non-

emergency, non-urgently needed services that are covered

under Medicare Part A or B and that are not related to your

terminal prognosis, your cost for these services depends on

whether you use a provider in our plan’s network:

• If you obtain the covered services from a network provider,

you only pay the plan cost-sharing amount for in-network

services

• If you obtain the covered services from an out-of-network

provider, you pay the cost-sharing under Fee-for-Service

Medicare (Original Medicare)

For services that are covered by MetroPlus Advantage Plan

(HMO SNP) but are not covered by Medicare Part A or B:

MetroPlus Advantage Plan (HMO SNP) will continue to cover

plan-covered services that are not covered under Part A or B

whether or not they are related to your terminal prognosis. You

pay your plan cost-sharing amount for these services.

For drugs that may be covered by the plan’s Part D benefit:

Drugs are never covered by both hospice and our plan at the

same time. For more information, please see Chapter 5, Section

9.4 (What if you’re in Medicare-certified hospice)

Note: If you need non-hospice care (care that is not related to

your terminal prognosis), you should contact us to arrange the

services.

Our plan covers hospice consultation services (one time only)

for a terminally ill person who hasn’t elected the hospice benefit.





Immunizations

Covered Medicare Part B services include:

• Pneumonia vaccine

• Flu shots, once each flu season in the fall and winter, with

additional flu shots if medically necessary

• Hepatitis B vaccine if you are at high or intermediate risk of

getting Hepatitis B

• Other vaccines if you are at risk and they meet Medicare

Part B coverage rules

We also cover some vaccines under our Part D prescription

drug benefit.



for the pneumonia,

influenza, and Hepatitis B

vaccines.





Inpatient hospital care*

Includes inpatient acute, inpatient rehabilitation, long-term care

hospitals and other types of inpatient hospital services.

Inpatient hospital care starts the day you are formally admitted

to the hospital with a doctor’s order. The day before you are discharged is your last inpatient day.

Covered services include but are not limited to:

• Semi-private room (or a private room if medically

necessary)

• Meals including special diets

• Regular nursing services

• Costs of special care units (such as intensive care or

coronary care units)

• Drugs and medications

• Lab tests

• X-rays and other radiology services

• Necessary surgical and medical supplies

• Use of appliances, such as wheelchairs

• Operating and recovery room costs

• Physical, occupational, and speech language therapy

• Inpatient substance abuse services


income and Medicaid

eligibility, you pay

$0 or:

• $1,364 deductible

• Days 1-60: $0 copayment

per day

• Days 61-90: $341

copayment per day

• 60 Lifetime Reserve

Days: $682 copayment per

day

Our plan covers 90 days for

an inpatient hospital stay.

Our plan also covers 60

“lifetime reserve days”.

These are additional days

that we cover. If your

hospital stay is longer than

90 days, you can use these

extra days. But once you

have used up these extra 60

days, your inpatient

hospital coverage will be

limited to 90 days.





Inpatient hospital care (continued)*

• Under certain conditions, the following types of transplants

are covered: corneal, kidney, kidney-pancreatic, heart, liver,

lung, heart/lung, bone marrow, stem cell, and

intestinal/multivisceral. If you need a transplant, we will

arrange to have your case reviewed by a Medicare-approved

transplant center that will decide whether you are a

candidate for a transplant. Transplant providers may be

local or outside of the service area. If our in-network

transplant services are outside the community pattern of

care, you may choose to go locally as long as the local

transplant providers are willing to accept the Original

Medicare rate. If MetroPlus Advantage Plan (HMO SNP)

provides transplant services at a location outside the pattern

of care for transplants in your community and you choose to

obtain transplants at this distant location, we will arrange or

pay for appropriate lodging and transportation costs for you

and a companion.

• Blood - including storage and administration. Coverage of whole blood and packed red cells begins only with the fourth pint of blood that you need - you must either pay the costs for the first 3 pints of blood you get in a calendar year or have the blood donated by you or someone else. All other components of blood are covered beginning with the first pint used.

• Physician services

Note: To be an inpatient, your provider must write an order to admit you formally as an inpatient of the hospital. Even if you stay in the hospital overnight, you might still be considered an “outpatient.” If you are not sure if you are an inpatient or an outpatient, you should ask the hospital staff.

You can also find more information in a Medicare fact sheet called “Are You a Hospital Inpatient or Outpatient? If You Have Medicare – Ask!” This fact sheet is available on the Web at https://www.medicare.gov/Pubs/pdf/11435.pdf or by calling 1-800-MEDICARE (1-800-633-4227). TTY users call 1-877-486-2048. You can call these numbers for free, 24 hours a day, 7 days a week.

If you get authorized

inpatient care at an out-of-

network hospital after your

emergency condition is

stabilized, your cost is the

cost-sharing you would pay

at a network hospital.

Prior authorization

required.

https://www.medicare.gov/Pubs/pdf/11435.pdf





Inpatient mental health care*

• Covered services include mental health care services that

require a hospital stay.

Our plan covers up to 190 days in a lifetime for inpatient

mental health care in a psychiatric hospital. The inpatient

hospital care limit does not apply to inpatient mental services

provided in a general hospital.

Our plan covers 90 days for an inpatient hospital stay. Our

plan also covers 60 “lifetime reserve days”. These are additional days that we cover. If your hospital stay is longer

than 90 days, you can use these extra days. But once you have

used up these extra 60 days, your inpatient hospital coverage

will be limited to 90 days.


income and Medicaid


$0 or:

• $1,364 deductible

• Days 1-60: $0 copayment

per day

• Days 61-90: $341

copayment per day

• 60 Lifetime Reserve Days: $682 copayment per

day

Prior authorization

required.





Inpatient stay: Covered services received in a hospital or

SNF during a non-covered inpatient stay

If you have exhausted your inpatient benefits or if the inpatient

stay is not reasonable and necessary, we will not cover your

inpatient stay. However, in some cases, we will cover certain

services you receive while you are in the hospital or the skilled

nursing facility (SNF). Covered services include but are not

limited to:

• Physician services

• Diagnostic tests (like lab tests)

• X-ray, radium, and isotope therapy including technician

materials and services

• Surgical dressings

• Splints, casts and other devices used to reduce fractures and

dislocations

• Prosthetics and orthotics devices (other than dental) that

replace all or part of an internal body organ (including

contiguous tissue), or all or part of the function of a

permanently inoperative or malfunctioning internal body

organ, including replacement or repairs of such devices

• Leg, arm, back, and neck braces; trusses; and artificial legs,

arms, and eyes including adjustments, repairs, and

replacements required because of breakage, wear, loss, or a

change in the patient’s physical condition • Physical therapy, speech therapy, and occupational therapy

These services are covered

at outpatient rates.

Medical nutrition therapy

This benefit is for people with diabetes, renal (kidney) disease

(but not on dialysis), or after a kidney transplant when referred

by your doctor.

We cover 3 hours of one-on-one counseling services during

your first year that you receive medical nutrition therapy

services under Medicare (this includes our plan, any other

Medicare Advantage plan, or Original Medicare), and 2 hours

each year after that. If your condition, treatment, or diagnosis

changes, you may be able to receive more hours of treatment

with a physician’s referral. A physician must prescribe these services and renew their referral yearly if your treatment is

needed into the next calendar year.




Medicare-covered medical

nutrition therapy services.






Medicare Diabetes Prevention Program (MDPP)

MDPP services will be covered for eligible Medicare There is no coinsurance,

beneficiaries under all Medicare health plans. copayment, or deductible

MDPP is a structured health behavior change intervention that for the MDPP benefit.

provides practical training in long-term dietary change, increased physical activity, and problem-solving strategies for overcoming challenges to sustaining weight loss and a healthy lifestyle.





Medicare Part B prescription drugs*

These drugs are covered under Part B of Original Medicare. Members of our plan receive coverage for these drugs through our plan. Covered drugs include:

• Drugs that usually aren’t self-administered by the patient and are injected or infused while you are getting physician, hospital outpatient, or ambulatory surgical center services

• Drugs you take using durable medical equipment (such as nebulizers) that were authorized by the plan

• Clotting factors you give yourself by injection if you have hemophilia

• Immunosuppressive drugs, if you were enrolled in Medicare Part A at the time of the organ transplant

• Injectable osteoporosis drugs, if you are homebound, have a bone fracture that a doctor certifies was related to post-menopausal osteoporosis, and cannot self-administer the drug

• Antigens

• Certain oral anti-cancer drugs and anti-nausea drugs

• Certain drugs for home dialysis, including heparin, the antidote for heparin when medically necessary, topical anesthetics, and erythropoiesis-stimulating agents (such as

Epogen, Procrit, Epoetin Alfa, Aranesp, or Darbepoetin Alfa)

• Intravenous Immune Globulin for the home treatment of primary immune deficiency diseases

Chapter 5 explains the Part D prescription drug benefit,

including rules you must follow to have prescriptions covered.

What you pay for your Part D prescription drugs through our

plan is explained in Chapter 6.


income and Medicaid


20% coinsurance

Prior authorization

required.

Some Part B drugs may be

subject to Step Therapy.

Obesity screening and therapy to promote sustained

weight loss

If you have a body mass index of 30 or more, we cover

intensive counseling to help you lose weight. This counseling is

covered if you get it in a primary care setting, where it can be

coordinated with your comprehensive prevention plan. Talk to

your primary care doctor or practitioner to find out more.



for preventive obesity

screening and therapy.





Outpatient diagnostic tests and therapeutic services and

supplies*


• X-rays

• Radiation (radium and isotope) therapy including technician

materials and supplies

• Surgical supplies, such as dressings

• Splints, casts and other devices used to reduce fractures and

dislocations

• Laboratory tests

• Blood - including storage and administration. Coverage of

whole blood and packed red cells begins only with the

fourth pint of blood that you need - you must either pay the

costs for the first 3 pints of blood you get in a calendar year

or have the blood donated by you or someone else. All other

components of blood are covered beginning with the first

pint used

• Other outpatient diagnostic tests


income and Medicaid


20% coinsurance

Prior authorization is

required for CT/MRI/MRA

and PET scans.





Outpatient hospital services

We cover medically-necessary services you get in the

outpatient department of a hospital for diagnosis or treatment of

an illness or injury.


• Services in an emergency department or outpatient clinic,

such as observation services or outpatient surgery

• Laboratory and diagnostic tests billed by the hospital

• Mental health care, including care in a partial-

hospitalization program, if a doctor certifies that inpatient

treatment would be required without it

• X-rays and other radiology services billed by the hospital

• Medical supplies such as splints and casts

• Certain drugs and biologicals that you can’t give yourself

Note: Unless the provider has written an order to admit you as

an inpatient to the hospital, you are an outpatient and pay the

cost-sharing amounts for outpatient hospital services. Even if

you stay in the hospital overnight, you might still be considered

an “outpatient.” If you are not sure if you are an outpatient, you

should ask the hospital staff.

You can also find more information in a Medicare fact sheet

called “Are You a Hospital Inpatient or Outpatient? If You

Have Medicare – Ask!” This fact sheet is available on the Web

at https://www.medicare.gov/Pubs/pdf/11435.pdf or by calling

1-800-MEDICARE (1-800-633-4227). TTY users call 1-877-

486-2048. You can call these numbers for free, 24 hours a day,

7 days a week.


income and Medicaid


20% coinsurance

Outpatient mental health care


Mental health services provided by a state-licensed psychiatrist

or doctor, clinical psychologist, clinical social worker, clinical

nurse specialist, nurse practitioner, physician assistant, or other

Medicare-qualified mental health care professional as allowed

under applicable state laws.


income and Medicaid


20% coinsurance






Outpatient rehabilitation services*

Covered services include: physical therapy, occupational

therapy, and speech language therapy.

Outpatient rehabilitation services are provided in various

outpatient settings, such as hospital outpatient departments,

independent therapist offices, and Comprehensive Outpatient

Rehabilitation Facilities (CORFs).


income and Medicaid


20% coinsurance

Prior authorization is

required for more than 10

visits in a year.

Outpatient substance abuse services

Coverage under Medicare Part B is available for treatment

services that are provided in the outpatient department of a

hospital to patients who, for example, have been discharged

from an inpatient stay for the treatment of drug substance abuse

or who require treatment but do not require the availability and

intensity of services found only in the inpatient hospital setting.


income and Medicaid


20% coinsurance

Outpatient surgery, including services provided at hospital

outpatient facilities and ambulatory surgical centers

Note: If you are having surgery in a hospital facility, you

should check with your provider about whether you will be an

inpatient or outpatient. Unless the provider writes an order to

admit you as an inpatient to the hospital, you are an outpatient

and pay the cost-sharing amounts for outpatient surgery. Even

if you stay in the hospital overnight, you might still be

considered an “outpatient.”


income and Medicaid


20% coinsurance

Partial hospitalization services*

“Partial hospitalization” is a structured program of active psychiatric treatment provided as a hospital outpatient service

or by a community mental health center, that is more intense

than the care received in your doctor’s or therapist’s office and

is an alternative to inpatient hospitalization.


income and Medicaid


20% coinsurance

Prior authorization

required.





Physician/Practitioner services, including doctor’s office visits


• Medically-necessary medical care or surgery services

furnished in a physician’s office, certified ambulatory surgical center, hospital outpatient department, or any other

location

• Consultation, diagnosis, and treatment by a specialist

• Basic hearing and balance exams performed by your PCP, if

your doctor orders it to see if you need medical treatment

• Certain telehealth services including consultation,

diagnosis, and treatment by a physician or practitioner for

patients in certain rural areas or other locations approved by

Medicare

• Second opinion by another network provider prior to

surgery

• Non-routine dental care (covered services are limited to

surgery of the jaw or related structures, setting fractures of

the jaw or facial bones, extraction of teeth to prepare the

jaw for radiation treatments of neoplastic cancer disease, or

services that would be covered when provided by a

physician)


income and Medicaid


20% coinsurance

Podiatry services


• Diagnosis and the medical or surgical treatment of injuries

and diseases of the feet (such as hammer toe or heel spurs)

• Routine foot care for members with certain medical

conditions affecting the lower limbs


income and Medicaid


20% coinsurance

Routine foot care (1 visit

per year): You pay nothing

Prostate cancer screening exams There is no coinsurance,

copayment, or deductible For men age 50 and older, covered services include the for an annual PSA test.following - once every 12 months:

• Digital rectal exam

• Prostate Specific Antigen (PSA) test





Prosthetic devices and related supplies*

Devices (other than dental) that replace all or part of a body

part or function. These include, but are not limited to:

colostomy bags and supplies directly related to colostomy care,

pacemakers, braces, prosthetic shoes, artificial limbs, and breast

prostheses (including a surgical brassiere after a mastectomy).

Includes certain supplies related to prosthetic devices, and

repair and/or replacement of prosthetic devices. Also includes

some coverage following cataract removal or cataract surgery – see “Vision Care” later in this section for more detail.


income and Medicaid


20% coinsurance

Prior authorization

required.

Pulmonary rehabilitation services*

Comprehensive programs of pulmonary rehabilitation are

covered for members who have moderate to very severe

chronic obstructive pulmonary disease (COPD) and a referral

for pulmonary rehabilitation from the doctor treating the

chronic respiratory disease.


income and Medicaid


20% coinsurance

Prior authorization

required.

Screening and counseling to reduce alcohol misuse

We cover one alcohol misuse screening for adults with

Medicare (including pregnant women) who misuse alcohol, but

aren’t alcohol dependent.

If you screen positive for alcohol misuse, you can get up to 4

brief face-to-face counseling sessions per year (if you’re competent and alert during counseling) provided by a qualified

primary care doctor or practitioner in a primary care setting.



for the Medicare-covered

screening and counseling to

reduce alcohol misuse

preventive benefit.





Screening for lung cancer with low dose computed

tomography (LDCT)

For qualified individuals, a LDCT is covered every 12 months.

Eligible members are: people aged 55 – 77 years who have no

signs or symptoms of lung cancer, but who have a history of

tobacco smoking of at least 30 pack-years and who currently

smoke or have quit smoking within the last 15 years, who

receive a written order for LDCT during a lung cancer screening

counseling and shared decision making visit that meets the

Medicare criteria for such visits and be furnished by a physician

or qualified non-physician practitioner.

For LDCT lung cancer screenings after the initial LDCT

screening: the member must receive a written order for LDCT

lung cancer screening, which may be furnished during any

appropriate visit with a physician or qualified non-physician

practitioner. If a physician or qualified non-physician

practitioner elects to provide a lung cancer screening counseling

and shared decision making visit for subsequent lung cancer

screenings with LDCT, the visit must meet the Medicare criteria

for such visits.



for the Medicare covered

counseling and shared

decision making visit or

for the LDCT.

Screening for sexually transmitted infections (STIs) and

counseling to prevent STIs

We cover sexually transmitted infection (STI) screenings for

chlamydia, gonorrhea, syphilis, and Hepatitis B. These

screenings are covered for pregnant women and for certain

people who are at increased risk for an STI when the tests are

ordered by a primary care provider. We cover these tests once

every 12 months or at certain times during pregnancy.

We also cover up to 2 individual 20 to 30 minute, face-to-face

high-intensity behavioral counseling sessions each year for

sexually active adults at increased risk for STIs. We will only

cover these counseling sessions as a preventive service if they

are provided by a primary care provider and take place in a

primary care setting, such as a doctor’s office.




screening for STIs and

counseling for STIs

preventive benefit.





Services to treat kidney disease


• Kidney disease education services to teach kidney care and

help members make informed decisions about their care.

For members with stage IV chronic kidney disease when

referred by their doctor, we cover up to six sessions of

kidney disease education services per lifetime.

• Outpatient dialysis treatments (including dialysis treatments

when temporarily out of the service area, as explained in

Chapter 3)

• Inpatient dialysis treatments (if you are admitted as an

inpatient to a hospital for special care)

• Self-dialysis training (includes training for you and anyone

helping you with your home dialysis treatments)

• Home dialysis equipment and supplies

• Certain home support services (such as, when necessary,

visits by trained dialysis workers to check on your home

dialysis, to help in emergencies, and check your dialysis

equipment and water supply)

Certain drugs for dialysis are covered under your Medicare Part

B drug benefit. For information about coverage for Part B

Drugs, please go to the section, “Medicare Part B prescription

drugs.”


income and Medicaid


20% coinsurance





Skilled nursing facility (SNF) care*

(For a definition of “skilled nursing facility care,” see Chapter 12 of this booklet. Skilled nursing facilities are sometimes called “SNFs.”)

Our plan covers up to 100 days in a SNF. You must have had at least a 3 day inpatient hospital stay prior to SNF admission. Covered services include but are not limited to:

• Semiprivate room (or a private room if medically necessary)

• Meals, including special diets

• Skilled nursing services

• Physical therapy, occupational therapy, and speech therapy

• Drugs administered to you as part of your plan of care (This includes substances that are naturally present in the body, such as blood clotting factors.)

• Blood - including storage and administration. Coverage of whole blood and packed red cells begins only with the fourth pint of blood that you need – you must either pay the costs for the first 3 pints of blood you get in a calendar year or have the blood donated by you or someone else. All other components of blood are covered beginning with the first pint used.

• Medical and surgical supplies ordinarily provided by SNFs

• Laboratory tests ordinarily provided by SNFs

• X-rays and other radiology services ordinarily provided by SNFs

• Use of appliances such as wheelchairs ordinarily provided by SNFs

• Physician/Practitioner services

Generally, you will get your SNF care from network facilities. However, under certain conditions listed below, you may be able to get your care from a facility that isn’t a network provider, if the facility accepts our plan’s amounts for payment.

• A nursing home or continuing care retirement community where you were living right before you went to the hospital (as long as it provides skilled nursing facility care)

• A SNF where your spouse is living at the time you leave the hospital


income and Medicaid


$0 or:

• You pay nothing (days 1-

20),

• $170.50 copay per day for

days 21-100

Prior authorization

required.





Smoking and tobacco use cessation (counseling to stop

smoking or tobacco use)

If you use tobacco, but do not have signs or symptoms of

tobacco-related disease: We cover two counseling quit attempts

within a 12-month period as a preventive service with no cost

to you. Each counseling attempt includes up to four face-to-face

visits.

If you use tobacco and have been diagnosed with a tobacco-

related disease or are taking medicine that may be affected by

tobacco: We cover cessation counseling services. We cover two

counseling quit attempts within a 12-month period; however,

you will pay the applicable cost-sharing. Each counseling

attempt includes up to four face-to-face visits.




smoking and tobacco use

cessation preventive

benefits.

Supervised Exercise Therapy (SET)

•

•

•

•


income and Medicaid


20% coinsurance

SET may be covered beyond 36 sessions over 12 weeks for an additional 36 sessions over an extended period of time if deemed medically necessary by a health care provider.





Urgently needed services

Urgently needed services are provided to treat a non-

emergency, unforeseen medical illness, injury, or condition that

requires immediate medical care. Urgently needed services may

be furnished by network providers or by out-of-network

providers when network providers are temporarily unavailable

or inaccessible.

Cost sharing for necessary urgently needed services furnished

out-of-network is the same as for such services furnished in-

network.

This coverage is available within the United States.


income and Medicaid


20% coinsurance (up to

$65)

Vision care


• Outpatient physician services for the diagnosis and

treatment of diseases and injuries of the eye, including

treatment for age-related macular degeneration. Original

Medicare doesn’t cover routine eye exams (eye refractions)

for eyeglasses/contacts

• For people who are at high risk of glaucoma, we will cover

one glaucoma screening each year. People at high risk of

glaucoma include: people with a family history of

glaucoma, people with diabetes, African-Americans who

are age 50 and older, and Hispanic Americans who are 65

or older

• For people with diabetes, screening for diabetic retinopathy

is covered once per year

One pair of eyeglasses or contact lenses after each cataract

surgery that includes insertion of an intraocular lens (If you

have two separate cataract operations, you cannot reserve the

benefit after the first surgery and purchase two eyeglasses after

the second surgery.)


income and Medicaid


20% coinsurance





Eyewear

Eyewear is covered up to a total of $100 per year for:

• Contact lenses

• Eyeglasses (lenses and frames)

• Eyeglass lenses

Eyeglass frames • • Upgrades

This benefit can be

combined with your

Medicaid benefits to

provide coverage

additional eyewear, or to

purchase eyewear beyond

the Medicaid spending

limit.

“Welcome to Medicare” Preventive Visit

The plan covers the one-time “Welcome to Medicare” preventive visit. The visit includes a review of your health, as

well as education and counseling about the preventive services

you need (including certain screenings and shots), and referrals

for other care if needed.



for the “Welcome to

Medicare” preventive visit.

Important: We cover the “Welcome to Medicare” preventive visit only within the first 12 months you have Medicare Part B.

When you make your appointment, let your doctor’s office know you would like to schedule your “Welcome to Medicare” preventive visit.

SECTION 3 What services are covered outside of MetroPlus Advantage Plan (HMO SNP)?

Section 3.1 Services not covered by MetroPlus Advantage Plan (HMO SNP)

The following services are not covered by MetroPlus Advantage Plan (HMO SNP) but are

available through Medicaid or people who qualify for full Medicaid benefits. Simply present

your New York State issued Medicaid identification (ID) card to obtain these additional

Medicaid-covered benefits.

Contact your Medicaid Agency to determine your level of cost sharing. Subject to changes in

state law, the following shall be considered Medicaid Benefits and shall be paid for by SDOH

for eligible Medicaid beneficiaries.

2019 Evidence of Coverage for MetroPlus Advantage Plan (HMO SNP) 88


Category of Service Description of Covered Services

Inpatient Hospital Services Inpatient Hospital services, as medically necessary,

shall include, except as otherwise specified, the care,

treatment, maintenance and nursing services as may be

required, on an inpatient hospital basis, up to 365 days

per year (366 leap year). Inpatient hospital services

encompass a full range of necessary diagnostic and

therapeutic care including medical, surgical, nursing,

radiological, and rehabilitative services.

*covered only when admit date precedes effective date

of enrollment*

Inpatient Stay Pending Alternate Level of

Medical Care

Inpatient stay pending alternate level of medical care,

or continued care in a hospital, Article 31 mental

health facility, or skilled nursing facility pending

placement in an alternate lower medical level of care

Physician Services Services, whether furnished in the office, the

Enrollee’s home, a hospital, a skilled nursing facility,

or elsewhere by a physician within the scope of

medicine as defined in law by the New York State

Education Department, and by or under the personal

supervision of an individual licensed and currently

registered by the New York State Education

Department to practice medicine. Includes the full

range of preventative care services, primary care

medical services and physician specialty services that

fall within a physician's scope of practice under New

York State law.

Nurse Practitioner Services Practitioner services include preventive services, the

diagnosis of illness and physical conditions, and the

performance of therapeutic and corrective measures,

within the scope of the certified nurse practitioner’s

licensure and collaborative practice agreement with a

licensed physician in accordance with the requirements

of the NYS Education Department.



Midwifery Services The management of normal pregnancy, childbirth and

Postpartum care as well as primary preventive

reproductive health care to essentially healthy women

and shall include newborn evaluation, resuscitation and

referral for infants. The care may be provided on an

inpatient or outpatient basis including in a birthing

center or in the Enrollee’s home as appropriate. The midwife must be licensed by the NYS Education

Department and have a collaborative relationship with

a physician or hospital that provides obstetric services,

that provides for consultation, collaborative

management and referral to address the health status

and risks of patients and includes plans for emergency

medical OB/GYN coverage.

Preventative Health Services Preventive health services means care and services to

avert disease/illness and/or its consequences. There are

three (3) levels of preventive health services: 1)

primary, such as immunizations, aimed at preventing

disease; 2) secondary, such as disease screening

programs aimed at early detection of disease; and 3)

tertiary, such as physical therapy, aimed at restoring

function after the disease has occurred.

Second Medical/Surgical Opinion Enrollees will be allowed to obtain second opinions for

diagnosis of a condition, treatment or surgical

procedure by a qualified physician or appropriate

specialist, including one affiliated with a specialty care

center. In the event that the Contractor determines that

it does not have a Participating Provider in its network

with appropriate training and experience qualifying the

Participating Provider to provide a second opinion, the

Contractor shall make a referral to an appropriate Non-

Participating Provider. The Contractor shall pay for the

cost of the services associated with obtaining a second

opinion regarding medical or surgical care, including

diagnostic and evaluation services, provided by the

Non-Participating Provider

Laboratory Services Laboratory services include medically necessary tests

and procedures ordered by a qualified medical

professional and listed in the Medicaid fee schedule for

a laboratory services



Radiology Services Radiology services include medically necessary

services provided by qualified practitioners in the

provision of diagnostic radiology, diagnostic

ultrasound, nuclear medicine, radiation oncology, and

magnetic resonance imaging (MRI). These services

may only be performed upon the order of a qualified

practitioner.

Prescription and Non-Prescription (OTC)

Drugs, Medical Supplies, and Enteral

Formula

Medically necessary prescription and nonprescription

(OTC) drugs, medical supplies, hearing aid batteries

and enteral formula are covered by MetroPlus when

ordered by a qualified provider. Pharmaceuticals and

medical supplies routinely furnished or administered as

part of a clinic or office visit and self-administered

injectable drugs (including those administered by a

family member and during a home care visit) not

included on the Medicaid outpatient formulary are

covered by MetroPlus

Smoking Cessation Products Prior authorization for smoking cessation products that

are included in the formulary and ordered by a

qualified provider is not required. A course of therapy

is defined as no more than a 90-day supply (an original

order and two refills, even if less than a 30-day supply

is dispensed on any fill).

Rehabilitation Services Services are provided for the maximum reduction of

physical or mental disability and restoration of the

Enrollee to his or her best functional level.

Rehabilitation services include care and services

rendered by physical therapists, speech-language

pathologists and occupational therapists.



EPSDT Services/Child Teen Health

Program (C/THP)

package of early and periodic screening, including

inter-periodic screens and, diagnostic and treatment

services that New York State offers all Medicaid

eligible children under twenty-one (21) years of age.

Care and

services shall be provided in accordance with the

periodicity schedule and guidelines developed by the

New York State Department of Health. The care

includes necessary health care, diagnostic services,

treatment and other measures to correct or ameliorate

defects, and physical and mental illnesses and

conditions discovered by the screening services

(regardless of whether the service is otherwise included

in the New York State Medicaid Plan). The package of

services includes administrative services designed to

assist families obtain services for children including

outreach, education, appointment scheduling,

administrative case management and transportation

assistance.

Home Health Services Home health services are: nursing services provided on

a part-time or intermittent basis by a CHHA or, if there

is no CHHA that services the county/district, by a

registered professional nurse or a licensed practical

nurse acting under the direction of the Enrollee’s PCP;

physical therapy, occupational therapy, or speech

pathology and audiology

services; and home health services provided by a

person who meets the training requirements of the

SDOH, is assigned by a registered professional nurse

to provide home health aid services in accordance with

the Enrollee’s plan of care, and is supervised by a registered professional nurse from a CHHA or a

registered nurse, or therapist.

Hospice Coordinated program of home and/or inpatient non-

curative medical and support services for terminally ill

persons and their families. Care focuses on easing

symptoms rather than treating disease. The patient and

his or her family receive physical, psychological, social

and spiritual support and care. Hospice provides four

levels of care: 1) routine home care, 2) respite care, 3)

continuous care, and 4) general inpatient care. The

program is available to persons with a medical

prognosis of six months or less to live for FHPlus or

one (1) year or less to live for MMC, if the terminal

illness runs its normal course.



Emergency Services

Post-Stabilization Care Services

Emergency services are Health care procedures,

treatments or services needed to

evaluate or stabilize an Emergency Medical Condition

including psychiatric stabilization

and medical detoxification from drugs or alcohol.

Post -Stabilization Services are those services related

to an Emergency Medical Condition, that are provided

after an Enrollee is stabilized in order to maintain the

stabilized condition, or to improve or resolve the

Enrollee’s condition.

Foot Care Services Routine foot care provided by qualified provider types

other than podiatrists when any Enrollee’s (regardless

of age) physical condition poses a hazard due to the

presence of localized illness, injury or symptoms

involving

the foot, or when performed as a necessary and integral

part of otherwise covered services such as the

diagnosis and treatment of diabetes, ulcers, and

infections. Routine hygienic care of the feet, the

treatment of corns and calluses, the trimming of nails,

and other hygienic care such as cleaning or soaking

feet, is not covered in the absence of a pathological

condition

Services provided by a podiatrist for persons under

twenty-one (21) must be covered upon referral of a

physician, registered physician assistant, certified nurse

practitioner or licensed midwife. Services provided by

a podiatrist for adults with diabetes mellitus are

covered.

Eye Care and Low Vision Services Eye care includes the services of ophthalmologists,

optometrists and ophthalmic dispensers, and includes

eyeglasses, medically necessary contact lenses and

polycarbonate lenses, artificial eyes (stock or custom-

made), low vision aids and low vision services.



Durable Medical Equipment (DME) Devices and equipment, other than medical/surgical

supplies, enteral formula, and prosthetic or orthotic

appliances, and have the following characteristics can

withstand repeated use for a protracted period of time;

are primarily and customarily used for medical

purposes; are generally not useful to a person in the

absence of illness or injury; and are usually not fitted,

designed or fashioned for a particular individual’s use.

Where equipment is intended for use by only one (1)

person, it may be either custom made or customized.

Audiology, Hearing Aids Services &

Products

Hearing aid services and products are provided in

compliance with Article 37-A of the General Business

Law when medically necessary to alleviate disability

caused by the loss or impairment of hearing. Hearing

aid services include: selecting, fitting and dispensing of

hearing aids, hearing aid checks following dispensing

of hearing aids, conformity evaluation, and hearing aid

repairs

Family Planning and Reproductive

Health Services

Family Planning and Reproductive Health Care

services means the offering, arranging and furnishing

of those health services which enable Enrollees,

including minors who may be sexually active, to

prevent or reduce the incidence of unwanted

pregnancy.

Non-Emergency Transportation Transportation expenses are covered when essential to

obtain necessary medical care services. Transportation

services means transportation by ambulance, ambulette

(invalid coach), fixed wing or airplane transport,

invalid coach, taxicab, livery, public transportation, or

other means appropriate to the MMC Enrollee’s

medical condition; and a transportation attendant to

accompany the MMC Enrollee, if necessary.

Emergency Transportation Emergency transportation means the provision of

ambulance transportation for the purpose of obtaining

hospital services for an Enrollee who suffers from

severe, life-threatening or potentially disabling

conditions which require the provision of Emergency

Services while the enrollee is being transported.

Emergency transportation can only be provided by an

ambulance service including air ambulance service.

Dental and Orthodontic Services Dental care includes preventative, prophylactic and

other routine dental care, services supplies and dental

prosthetics required to alleviate a serious health

condition, including one which affects employability.



Court-Ordered Services Court ordered services are those services ordered by a

court of competent jurisdiction which are performed by

or under the supervision of a physician, dentist, or

other provider qualified under State law to furnish

medical, dental, behavioral health (including treatment

for mental health and/or alcohol and/or substance

abuse or dependence), or other covered services.

Prosthetic/Orthotic Services/ Orthopedic

Footwear

Prosthetics are those appliances or devices which

replace or perform the function of any missing part of

the body. Artificial eyes are covered as part of the eye

care benefit.

Orthotics are those appliances or devices which are

used for the purpose of supporting a weak or deformed

body part or to restrict or eliminate motion in a

diseased or injured part of the body.

Footwear means shoes, shoe modifications, or shoe

additions which are used to correct, accommodate or

prevent a physical deformity or range of motion

malfunction in a diseased or injured part of the ankle or

foot; to support a weak or deformed structure of the

ankle or foot, or to form an integral part of a brace.

Mental Health Services All Inpatient mental health services, including

voluntary or involuntary admissions for mental health

services.

Outpatient mental health services, include but are not

limited to: assessment, stabilization, treatment

planning, discharge planning, verbal therapies,

education, symptom management, case management

services, crisis intervention and outreach services,

chlozapine monitoring and collateral services.

Services may be provided in-home, office, or the

community.



SUD Inpatient Detoxification Services Medically directed twenty-four (24) hour care on an

inpatient basis to individuals who are at risk of severe

alcohol or substance abuse withdrawal, incapacitated, a

risk to self or others, or diagnosed with an acute

physical or mental co-morbidity. Specific services

include, but are not limited to: medical management,

bio-psychosocial assessments, stabilization of medical

psychiatric / psychological problems, individual and

group counseling, level of care determinations and

referral and linkages to other services as necessary.

Treatment for moderate withdrawal on an inpatient

basis. Services must include medical supervision and

direction under the care of a physician in the treatment

for moderate withdrawal. Specific services must

include but are not limited to: medical assessment

within twenty four (24) hours of admission; medical

supervision of intoxication and withdrawal conditions;

bio-psychosocial assessments; individual and group

counseling and linkages to other services as necessary.

SUD Inpatient Rehabilitation and

Treatment Services

Services include intensive management of chemical

dependence symptoms and medical management of

physical or mental complications from chemical

dependence to clients who cannot be effectively served

on an outpatient basis and who are not in need of

medical detoxication or acute care. Can include but not

limited to: comprehensive admission evaluation and

treatment planning; individual group, and family

counseling; awareness and relapse prevention;

education about self-help groups; assessment and

referral services; vocational and educational

assessment; medical and psychiatric consultation; food

and housing; and HIV and AIDS education.

SUD Residential Addiction Treatment

Services

Residential addiction services include individual

centered residential services consistent with the

individual’s assessed treatment needs, with a rehabilitation and recovery focus designed to promote

skills for coping with and managing substance use

disorder symptoms and behaviors. Services also

address an individual’s major lifestyle, attitudinal, and

behavioral problems that have the potential to

undermine the goals of treatment.



SUD Outpatient Services

SUD Medically Supervised Outpatient

Withdrawal

Includes:

Medically Supervised Ambulatory Chemical

Dependence Outpatient Clinic Programs are licensed to

deliver service to individuals who suffer from chemical

abuse or dependence and/or their family members or

significant others.

Medically Supervised Chemical Dependence

Outpatient Rehabilitation Programs provide outpatient

rehabilitation services for individuals with more

chronic SUD conditions and emphasize development

of basic skills in prevocational and vocational

competencies, personal care, nutrition, and community

competency. The individual must have an adequate

support system and either substantial deficits in

interpersonal and functional skills or health care needs

requiring attention or monitoring by health care staff.

These services are provided in combination with all

other clinical services provided by CD-OPs.

Outpatient Chemical Dependence for Youth Programs

which offer discrete, ambulatory clinic services to

chemically-dependent youth in a treatment setting that

supports abstinence from chemical dependence

(including alcohol and substance abuse) services.

Opioid Treatment Program means one or more OASAS

certified sites where methadone or other approved

medications are administered to treat opioid

dependency. OTPs may provide patients with any or all

of the following: Opioid detoxification; Opioid

medical maintenance; and Opioid taper. The term

“OTP” encompasses medical and support services at

the certified site or in the community including

counseling, educational and vocational rehabilitation.

OTP also includes the Narcotic Treatment Program

(NTP) as defined by the federal Drug Enforcement

Agency

These programs offer treatment for moderate

withdrawal on an outpatient basis. Required services

include, but are not limited to: medical supervision of

intoxication and withdrawal conditions; bio-

psychosocial assessments; individual and group

counseling; level of care determinations; discharge

planning; and referrals to appropriate services.



Buprenorphine Prescribers Management and/or Prescription of buphrenorphine by

Primary Care Providers and Mental Health Providers

for maintenance or detoxication of patients with

Substance Use Disorder

Experimental and/or Investigational Experimental or investigational treatment for life-

Treatment threatening and/or disabling

illnesses may also be considered for coverage under

the external appeal process

Renal Dialysis Renal dialysis may be provided in an inpatient hospital

setting, in an ambulatory care

facility, or in the home on recommendation from a

renal dialysis center

Residential Health Care Facility (Nursing

Home) Services (RHCF)

Inpatient nursing home services provided by facilities

licensed under Article 28 of the New York State Public

Health Law, including AIDS nursing facilities.

Covered services include the following health care

services: medical supervision, twenty-four (24) hour

per day nursing care, assistance with the activities of

daily living, physical therapy, occupational therapy,

and speech/language pathology services and other

services as specified in the New York State Health

Law and Regulations for residential health care

facilities and AIDS nursing facilities.

Personal Care Services Some or total assistance with personal hygiene,

dressing and feeding and nutritional and environmental

support (meal preparation and housekeeping). Such

services must be essential to the maintenance of the

Enrollee’s health and safety in his or her own home.

The service must be ordered by a physician or nurse

practitioner, and there must be a medical need for the

service

Personal Emergency Response System

(PERS)

Personal Emergency Response System (PERS) is an

electronic device which enables

certain high-risk patients to secure help in the event of

a physical, emotional or

environmental emergency. Such systems are usually

connected to a patient’s phone and signal a response center when a “help” button is

activated. In the event of an

emergency, the signal is received and appropriately

acted upon by a response center.



Consumer Directed Personal Assistance

Services

Consumer Directed Personal Assistance Services

means the provision to a chronically ill and/or disabled

Consumer of some or total assistance with personal

care services, home health aide

services and skilled nursing tasks by a consumer

directed personal assistant under the

instruction, supervision and direction of a Consumer or

the Consumer’s designated representative.

Observation Services Post-stabilization services for observation, short-term

treatment, assessment and re-assessment of an

Enrollee for whom diagnosis and a determination

concerning inpatient admission, discharge, or transfer

cannot be accomplished within eight hours but can

reasonably be

expected within forty-eight (48) hours. Observation

services may be provided in distinct

units approved by the Department, inpatient beds, or in

the emergency department ONLY for hospitals

designated as critical access hospitals or sole

community hospitals.

Medical Social Services An assessment of social and environmental factors

related to the participant’s illness, need for care,

response to treatment and adjustments to treatment;

assessment of the relationship of the participant’s

medical and nursing requirements to his/her home

situation, financial resources and availability of

community resources; actions to obtain available

community resources to assist in resolving the

participant’s problems; and counseling services. Such

services shall include, but not be limited to, home visits

to the individual, family or both; visits preparatory to

the transfer of the individual to the community; and

patient and family counseling, including personal,

financial, and other forms of counseling services.

Home Delivered Meals Home Delivered Meals are covered only for those

Enrollees who have transitioned to the Contractor’s

Medicaid Managed Care plan from the Long Term

Home Health Care Program (LTHHCP) and who

received Home Delivered Meals while in the

LTHHCP. Home Delivered Meals must be provided

when the Enrollee’s needs cannot be met by existing support services, including family and approved

personal care aides.



Adult Day Health Care Care and services provided to a registrant in a

residential health care facility or approved extension

site under the medical direction of a physician and

which is provided by personnel of the Adult Day

Health Care program in accordance with

comprehensive assessment of care needs and PCSP,

ongoing implementation and coordination of the PCSP,

and transportation

AIDS Adult Day Health Care AIDS Adult Day Health Care Programs are programs

designed to assist individuals with HIV disease to live

more independently in the community or eliminate the

need for residential health care services.

Tuberculosis Directly Observed Therapy Direct Observation of oral ingestion or the

administration of injectable/ infused medication, to

assure patient compliance with the physician's

prescribed medication regimen. DOT is the standard of

care for every individual with active TB.

Private duty Nursing Private duty nursing is the care of enrollees by nurses

who provide private duty care and are working one-to-

one with an individual enrollee. Private duty nursing

can be provided in the client's home, or an institution,

such as a hospital, nursing home or other such facility.

Harm Reduction Services Harm Reduction Services offer a complete patient-

oriented approach to reducing substance use and other

related harms. Harm Reduction services include an

initial assessment for the development of a plan of

care, individual and group supportive counseling,

medication management and treatment adherence

counseling, and psychoeducation support groups.

Pasteurized Donor Human Milk Pasteurized Donor Human Milk are services for an

infant who is medically or physically unable to receive

maternal breast milk or participate in breast feeding or

whose mother is medically or physically unable to

produce maternal breast milk at all or in sufficient

quantities or participate in breast feeding despite

optimal lactation

Transgender Related Care and Services Transgender related care and services includes

medically necessary hormone therapy and/or gender

reassignment surgery for the treatment of gender

dysphoria.



SECTION 4 What services are not covered by the plan?

Section 4.1 Services not covered by the plan (exclusions)

This section tells you what services are “excluded”. Excluded means that the plan doesn’t cover

these services.

The chart below describes some services and items that aren’t covered by the plan under any

conditions or are covered by the plan only under specific conditions.

We won’t pay for the excluded medical services listed in the chart below except under the

specific conditions listed. The only exception: we will pay if a service in the chart below is found

upon appeal to be a medical service that we should have paid for or covered because of your

specific situation. (For information about appealing a decision we have made to not cover a

medical service, go to Chapter 9, Section 6.3 in this booklet.)

All exclusions or limitations on services are described in the Benefits Chart or in the chart below.

Services not covered by

Medicare

Not covered under

any condition

Covered only under specific

conditions

Services considered not

reasonable and necessary,

according to the standards of

Original Medicare

Experimental medical and

surgical procedures, equipment

and medications

Experimental procedures and

items are those items and

procedures determined by our

plan and Original Medicare to

not be generally accepted by

the medical community.

May be covered by Original

Medicare under a Medicare-

approved clinical research study or

by our plan

(See Chapter 3, Section 5 for more

information on clinical research

studies.)

Private room in a hospital

Covered only when medically

necessary

Personal items in your room at

a hospital or a skilled nursing

facility, such as a telephone or

a television

Full-time nursing care in your

home




Medicare

Not covered under

any condition


conditions

*Custodial care is care

provided in a nursing home,

hospice, or other facility

setting when you do not

require skilled medical care or

skilled nursing care.

Homemaker services include

basic household assistance,

including light housekeeping

or light meal preparation.

Fees charged for care by your

immediate relatives or

members of your household

Cosmetic surgery or

procedures • Covered in cases of an

accidental injury or for

improvement of the functioning

of a malformed body member

• Covered for all stages of

reconstruction for a breast after a

mastectomy, as well as for the

unaffected breast to produce a

symmetrical appearance

Routine dental care, such as

cleanings, fillings or dentures Medicaid provides some routine

dental coverage

Non-routine dental care

Dental care required to treat illness

or injury may be covered as

inpatient or outpatient care.

Routine chiropractic care

Manual manipulation of the spine to

correct a subluxation is covered.

Routine foot care

Some limited coverage provided

according to Medicare guidelines,

e.g., if you have diabetes.




Medicare

Not covered under

any condition


conditions

Home-delivered meals

Orthopedic shoes

If shoes are part of a leg brace and

are included in the cost of the brace,

or the shoes are for a person with

diabetic foot disease.

Supportive devices for the feet

Orthopedic or therapeutic shoes for

people with diabetic foot disease

Routine hearing exams,

hearing aids, or exams to fit

hearing aids

Routine eye examinations,

eyeglasses, radial keratotomy,

LASIK surgery, and other low

vision aids

Eye exam and one pair of eyeglasses

(or contact lenses) are covered for

people after cataract surgery.

Reversal of sterilization

procedures and or non-

prescription contraceptive

supplies

Acupuncture

Naturopath services (uses

natural or alternative

treatments)

*Custodial care is personal care that does not require the continuing attention of trained medical

or paramedical personnel, such as care that helps you with activities of daily living, such as

bathing or dressing.

CHAPTER 5

Using the plan’s coverage for your Part D prescription drugs


Chapter 5. Using the plan’s coverage for your Part D prescription drugs


SECTION 1 Introduction .................................................................................... 106

Section 1.1 This chapter describes your coverage for Part D drugs............................... 106

Section 1.2 Basic rules for the plan’s Part D drug coverage .......................................... 107

SECTION 2 Fill your prescription at a network pharmacy or through the plan’s mail-order service ............................................................... 107

Section 2.1 To have your prescription covered, use a network pharmacy..................... 107

Section 2.2 Finding network pharmacies ....................................................................... 107

Section 2.3 Using the plan’s mail-order services ........................................................... 108

Section 2.4 How can you get a long-term supply of drugs?........................................... 109

Section 2.5 When can you use a pharmacy that is not in the plan’s network?............... 110

SECTION 3 Your drugs need to be on the plan’s “Drug List” ........................ 110

Section 3.1 The “Drug List” tells which Part D drugs are covered................................ 110

Section 3.2 There are two “cost-sharing tiers” for drugs on the Drug List .................... 111

Section 3.3 How can you find out if a specific drug is on the Drug List? ..................... 112

SECTION 4 There are restrictions on coverage for some drugs.................... 112

Section 4.1 Why do some drugs have restrictions?........................................................ 112

Section 4.2 What kinds of restrictions?.......................................................................... 112

Section 4.3 Do any of these restrictions apply to your drugs? ....................................... 113

SECTION 5 What if one of your drugs is not covered in the way you’d like it to be covered?...................................................................... 114

Section 5.1 There are things you can do if your drug is not covered in the way you’d

like it to be covered ..................................................................................... 114

Section 5.2 What can you do if your drug is not on the Drug List or if the drug is

restricted in some way? ............................................................................... 114

Section 5.3 What can you do if your drug is in a cost-sharing tier you think is too

high? ............................................................................................................ 116

SECTION 6 What if your coverage changes for one of your drugs? ............. 117

Section 6.1 The Drug List can change during the year .................................................. 117

Section 6.2 What happens if coverage changes for a drug you are taking? ................... 117

SECTION 7 What types of drugs are not covered by the plan? ..................... 119

Section 7.1 Types of drugs we do not cover .................................................................. 119



SECTION 8 Show your plan membership card when you fill a prescription..................................................................................... 120

Section 8.1 Show your membership card ....................................................................... 120

Section 8.2 What if you don’t have your membership card with you? .......................... 120

SECTION 9 Part D drug coverage in special situations .................................. 121

Section 9.1 What if you’re in a hospital or a skilled nursing facility for a stay that is covered by the plan?.................................................................................... 121

Section 9.2 What if you’re a resident in a long-term care (LTC) facility? .................... 121

Section 9.3 What if you’re also getting drug coverage from an employer or retiree group plan? .................................................................................................. 122

Section 9.4 What if you’re in Medicare-certified hospice?............................................ 122

SECTION 10 Programs on drug safety and managing medications ................ 123

Section 10.1 Programs to help members use drugs safely ............................................... 123

Section 10.2 Drug Management Program (DMP) to help members safely use their

opioid medications ...................................................................................... 123

Section 10.3 Medication Therapy Management (MTM) program to help members

manage their medications............................................................................ 124



How can you get information about your drug costs if you’re receiving

“Extra Help” with your Part D prescription drug costs?

Most of our members qualify for and are getting “Extra Help” from Medicare to pay for their prescription drug plan costs. If you are in the “Extra Help” program, some

information in this Evidence of Coverage about the costs for Part D prescription

drugs may not apply to you. We sent you a separate insert, called the “Evidence of

Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” (also

known as the “Low Income Subsidy Rider” or the “LIS Rider”), which tells you about

your drug coverage. If you don’t have this insert, please call Member Services and ask

for the “LIS Rider.” (Phone numbers for Member Services are printed on the back cover

of this booklet.)


Section 1.1 This chapter describes your coverage for Part D drugs

This chapter explains rules for using your coverage for Part D drugs. The next chapter tells

what you pay for Part D drugs (Chapter 6, What you pay for your Part D prescription drugs).

In addition to your coverage for Part D drugs, MetroPlus Advantage Plan (HMO SNP) also

covers some drugs under the plan’s medical benefits. Through its coverage of Medicare Part A

benefits, our plan generally covers drugs you are given during covered stays in the hospital or in

a skilled nursing facility. Through its coverage of Medicare Part B benefits, our plan covers

drugs including certain chemotherapy drugs, certain drug injections you are given during an

office visit, and drugs you are given at a dialysis facility. Chapter 4 (Medical Benefits Chart,

what is covered and what you pay) tells about the benefits and costs for drugs during a covered

hospital or skilled nursing facility stay, as well as your benefits and costs for Part B drugs.

Your drugs may be covered by Original Medicare if you are in Medicare hospice. Our plan only

covers Medicare Parts A, B, and D services and drugs that are unrelated to your terminal

prognosis and related conditions and therefore not covered under the Medicare hospice benefit.

For more information, please see Section 9.4 (What if you’re in Medicare-certified hospice). For

information on hospice coverage, see the hospice section of Chapter 4 (Medical Benefits Chart,

what is covered and what you pay).

The following sections discuss coverage of your drugs under the plan’s Part D benefit rules.

Section 9, Part D drug coverage in special situations includes more information on your Part D

coverage and Original Medicare.

In addition to the drugs covered by Medicare, some prescription drugs are covered for you under

your Medicaid benefits. For additional information on drugs covered by Medicaid, contact the

New York Medicaid CHOICE Hotline at 1-800-505-5678.



Section 1.2 Basic rules for the plan’s Part D drug coverage

The plan will generally cover your drugs as long as you follow these basic rules:

• You must have a provider (a doctor, dentist or other prescriber) write your prescription.

• Your prescriber must either accept Medicare or file documentation with CMS showing

that he or she is qualified to write prescriptions, or your Part D claim will be denied. You

should ask your prescribers the next time you call or visit if they meet this condition. If

not, please be aware it takes time for your prescriber to submit the necessary paperwork

to be processed.

• You generally must use a network pharmacy to fill your prescription. (See Section 2, Fill

your prescriptions at a network pharmacy or through the plan’s mail-order service.)

• Your drug must be on the plan’s List of Covered Drugs (Formulary) (we call it the “Drug List” for short). (See Section 3, Your drugs need to be on the plan’s “Drug List.”)

• Your drug must be used for a medically accepted indication. A “medically accepted

indication” is a use of the drug that is either approved by the Food and Drug Administration or supported by certain reference books. (See Section 3 for more

information about a medically accepted indication.)

SECTION 2 Fill your prescription at a network pharmacy or through the plan’s mail-order service

Section 2.1 To have your prescription covered, use a network pharmacy

In most cases, your prescriptions are covered only if they are filled at the plan’s network pharmacies. (See Section 2.5 for information about when we would cover prescriptions filled at

out-of-network pharmacies.)

A network pharmacy is a pharmacy that has a contract with the plan to provide your covered

prescription drugs. The term “covered drugs” means all of the Part D prescription drugs that are

covered on the plan’s Drug List.

Section 2.2 Finding network pharmacies

How do you find a network pharmacy in your area?

To find a network pharmacy, you can look in your Provider/Pharmacy Directory, visit our

website (www.metroplusmedicare.org), or call Member Services (phone numbers are printed

on the back cover of this booklet).

You may go to any of our network pharmacies. If you switch from one network pharmacy to

another, and you need a refill of a drug you have been taking, you can ask either to have a new




prescription written by a provider or to have your prescription transferred to your new network

pharmacy.

What if the pharmacy you have been using leaves the network?

If the pharmacy you have been using leaves the plan’s network, you will have to find a new

pharmacy that is in the network. To find another network pharmacy in your area, you can get

help from Member Services (phone numbers are printed on the back cover of this booklet) or use

the Provider/Pharmacy Directory. You can also find information on our website at


What if you need a specialized pharmacy?

Sometimes prescriptions must be filled at a specialized pharmacy. Specialized pharmacies

include:

• Pharmacies that supply drugs for home infusion therapy.

• Pharmacies that supply drugs for residents of a long-term care (LTC) facility. Usually, a

long-term care facility (such as a nursing home) has its own pharmacy. If you are in an

LTC facility, we must ensure that you are able to routinely receive your Part D benefits

through our network of LTC pharmacies, which is typically the pharmacy that the LTC

facility uses. If you have any difficulty accessing your Part D benefits in an LTC facility,

please contact Member Services.

• Pharmacies that serve the Indian Health Service / Tribal / Urban Indian Health Program

(not available in Puerto Rico). Except in emergencies, only Native Americans or Alaska

Natives have access to these pharmacies in our network.

• Pharmacies that dispense drugs that are restricted by the FDA to certain locations or that

require special handling, provider coordination, or education on their use. (Note: This

scenario should happen rarely.)

To locate a specialized pharmacy, look in your Pharmacy Directory or call Member Services

(phone numbers are printed on the back cover of this booklet).

Section 2.3 Using the plan’s mail-order services

For certain kinds of drugs, you can use the plan’s network mail-order services. Generally, the

drugs provided through mail order are drugs that you take on a regular basis, for a chronic or

long-term medical condition. The drugs that are not available through the plan’s mail-order

service are marked with an “NM” in our Drug List.

Our plan’s mail-order service requires you to order at least a 30-day supply of the drug and no

more than a 90-day supply.

To get order forms and information about filling your prescriptions by mail call Member Services

(phone numbers are printed on the back of this booklet).




Usually a mail-order pharmacy order will get to you in no more than 7-10 days for a new

prescription, and 3-4 days for a refill. If there is a delay in receiving your mail order, call

Member Services for an override that will allow you to pick up a 30-day supply of your

prescription at a retail pharmacy.

New prescriptions the pharmacy receives directly from your doctor’s office.

After the pharmacy receives a prescription from a health care provider, it will contact you to see

if you want the medication filled immediately or at a later time. This will give you an

opportunity to make sure that the pharmacy is delivering the correct drug (including strength,

amount, and form) and, if needed, allow you to stop or delay the order before you are billed and

it is shipped. It is important that you respond each time you are contacted by the pharmacy, to let

them know what to do with the new prescription and to prevent any delays in shipping.

Refills on mail-order prescriptions. For refills of your drugs, you have the option to sign up for

an automatic refill program. Under this program we will start to process your next refill

automatically when our records show you should be close to running out of your drug. The

pharmacy will contact you prior to shipping each refill to make sure you are in need of more

medication, and you can cancel scheduled refills if you have enough of your medication or if

your medication has changed. If you choose not to use our auto refill program, please contact

your pharmacy 10 days before you think the drugs you have on hand will run out to make sure

your next order is shipped to you in time.

To opt out of our program automatically prepares mail-order refills, please contact us by calling

Member Services (numbers are printed on the back of this booklet).

So the pharmacy can reach you to confirm your order before shipping, please make sure to let the

pharmacy know the best ways to contact you. Call Member Services (numbers are printed on the

back of this booklet) for assistance.

Section 2.4 How can you get a long-term supply of drugs?

When you get a long-term supply of drugs, your cost-sharing may be lower. The plan offers two

ways to get a long-term supply (also called an “extended supply”) of “maintenance” drugs on our

plan’s Drug List. (Maintenance drugs are drugs that you take on a regular basis, for a chronic or

long-term medical condition.) You may order this supply through mail order (see Section 2.3) or

you may go to a retail pharmacy.

1. Some retail pharmacies in our network allow you to get a long-term supply of

maintenance drugs. Your Provider/Pharmacy Directory tells you which pharmacies in our

network can give you a long-term supply of maintenance drugs. You can also call

Member Services for more information (phone numbers are printed on the back cover of

this booklet).

2. For certain kinds of drugs, you can use the plan’s network mail-order services. The

drugs that are not available through the plan’s mail-order service are marked with an

“NM” in our Drug List. Our plan’s mail-order service requires you to order at least a 30-



day supply of the drug and no more than a 90-day supply. See Section 2.3 for more

information about using our mail-order services.

Section 2.5 When can you use a pharmacy that is not in the plan’s network?

Your prescription may be covered in certain situations

Generally, we cover drugs filled at an out-of-network pharmacy only when you are not able to

use a network pharmacy. To help you, we have network pharmacies outside of our service area

where you can get your prescriptions filled as a member of our plan. If you cannot use a network

pharmacy, here are the circumstances when we would cover prescriptions filled at an out-of-

network pharmacy:

• If you are traveling within the United States and territories and become ill, lose or run out

of your prescription drugs. Note: We cannot pay for any prescriptions that are filled by

pharmacies outside of the United States and territories, even for medical emergency.

• You need prescriptions related to care for a medical emergency or urgent care. If you are

unable to obtain a covered drug in a timely manner within our service area, because there

is no network pharmacy within reasonable driving distance that provides 24-hour service.

Contact Member Services to see if your situation qualifies, and for any information about

limits.

In these situations, please check first with Member Services to see if there is a network

pharmacy nearby. (Phone numbers for Member Services are printed on the back cover of this

booklet.) You may be required to pay the difference between what you pay for the drug at the

out-of-network pharmacy and the cost that we would cover at an in-network pharmacy.

How do you ask for reimbursement from the plan?

If you must use an out-of-network pharmacy, you will generally have to pay the full cost (rather

than your normal share of the cost) at the time you fill your prescription. You can ask us to

reimburse you for our share of the cost. (Chapter 7, Section 2.1 explains how to ask the plan to

pay you back.)

SECTION 3 Your drugs need to be on the plan’s “Drug List”

Section 3.1 The “Drug List” tells which Part D drugs are covered

The plan has a “List of Covered Drugs (Formulary).” In this Evidence of Coverage, we call it

the “Drug List” for short.

The drugs on this list are selected by the plan with the help of a team of doctors and pharmacists.

The list must meet requirements set by Medicare. Medicare has approved the plan’s Drug List.



The Drug List includes the drugs covered under Medicare Part D (earlier in this chapter, Section

1.1 explains about Part D drugs). In addition to the drugs covered by Medicare, some

prescription drugs are covered for you under your Medicaid benefits. For additional information

on drugs covered by Medicaid, contact the New York Medicaid CHOICE Hotline at 1-800-505-

5678.

We will generally cover a drug on the plan’s Drug List as long as you follow the other coverage

rules explained in this chapter and the use of the drug is a medically accepted indication. A

“medically accepted indication” is a use of the drug that is either:

• Approved by the Food and Drug Administration. (That is, the Food and Drug

Administration has approved the drug for the diagnosis or condition for which it is being

prescribed.)

• -- or -- Supported by certain reference books. (These reference books are the American

Hospital Formulary Service Drug Information; the DRUGDEX Information System; the

USPDI or its successor; and, for cancer, the National Comprehensive Cancer Network

and Clinical Pharmacology or their successors.)

The Drug List includes both brand name and generic drugs

A generic drug is a prescription drug that has the same active ingredients as the brand name drug.

Generally, it works just as well as the brand name drug and usually costs less. There are generic

drug substitutes available for many brand name drugs.

What is not on the Drug List?

Medicaid-covered drugs are not on the Drug List. For additional information on drugs covered

by Medicaid, contact the New York Medicaid CHOICE Hotline at 1-800-505-5678.

The plan does not cover all prescription drugs.

• In some cases, the law does not allow any Medicare plan to cover certain types of drugs

(for more information about this, see Section 7.1 in this chapter).

• In other cases, we have decided not to include a particular drug on our Drug List.

Section 3.2 There are two “cost-sharing tiers” for drugs on the Drug List

Every drug on the plan’s Drug List is in one of two cost-sharing tiers. In general, the higher the

cost-sharing tier, the higher your cost for the drug:

• Cost-Sharing Tier 1 includes generic drugs and preferred multi-source drugs. This is the

lowest tier.

• Cost-Sharing Tier 2 includes all other drugs. This is the highest tier.

To find out which cost-sharing tier your drug is in, look it up in the plan’s Drug List.



The amount you pay for drugs in each cost-sharing tier is shown in Chapter 6 (What you pay for

your Part D prescription drugs).

Section 3.3 How can you find out if a specific drug is on the Drug List?

You have two ways to find out:

1. Visit the plan’s website (www.metroplusmedicare.org). The Drug List on the website is

always the most current.

2. Call Member Services to find out if a particular drug is on the plan’s Drug List or to ask

for a copy of the list. (Phone numbers for Member Services are printed on the back cover

of this booklet.)

SECTION 4 There are restrictions on coverage for some drugs

Section 4.1 Why do some drugs have restrictions?

For certain prescription drugs, special rules restrict how and when the plan covers them. A team

of doctors and pharmacists developed these rules to help our members use drugs in the most

effective ways. These special rules also help control overall drug costs, which keeps your drug

coverage more affordable.

In general, our rules encourage you to get a drug that works for your medical condition and is

safe and effective. Whenever a safe, lower-cost drug will work just as well medically as a higher-

cost drug, the plan’s rules are designed to encourage you and your provider to use that lower-cost

option. We also need to comply with Medicare’s rules and regulations for drug coverage and

cost-sharing.

If there is a restriction for your drug, it usually means that you or your provider will have

to take extra steps in order for us to cover the drug. If you want us to waive the restriction for

you, you will need to use the coverage decision process and ask us to make an exception. We

may or may not agree to waive the restriction for you. (See Chapter 9, Section 7.2 for

information about asking for exceptions.)

Please note that sometimes a drug may appear more than once in our drug list. This is because

different restrictions or cost-sharing may apply based on factors such as the strength, amount, or

form of the drug prescribed by your health care provider (for instance, 10 mg versus 100 mg; one

per day versus two per day; tablet versus liquid).

Section 4.2 What kinds of restrictions?

Our plan uses different types of restrictions to help our members use drugs in the most effective

ways. The sections below tell you more about the types of restrictions we use for certain drugs.




Restricting brand name drugs when a generic version is available

Generally, a “generic” drug works the same as a brand name drug and usually costs less. In most

cases, when a generic version of a brand name drug is available, our network pharmacies

will provide you the generic version. We usually will not cover the brand name drug when a

generic version is available. However, if your provider has told us the medical reason that neither

the generic drug nor other covered drugs that treat the same condition will work for you, then we

will cover the brand name drug. (Your share of the cost may be greater for the brand name drug

than for the generic drug.)

Getting plan approval in advance

For certain drugs, you or your provider need to get approval from the plan before we will agree

to cover the drug for you. This is called “prior authorization.” Sometimes the requirement for getting approval in advance helps guide appropriate use of certain drugs. If you do not get this

approval, your drug might not be covered by the plan.

Trying a different drug first

This requirement encourages you to try less costly but just as effective drugs before the plan

covers another drug. For example, if Drug A and Drug B treat the same medical condition, the

plan may require you to try Drug A first. If Drug A does not work for you, the plan will then

cover Drug B. This requirement to try a different drug first is called “step therapy.”

Quantity limits

For certain drugs, we limit the amount of the drug that you can have by limiting how much of a

drug you can get each time you fill your prescription. For example, if it is normally considered

safe to take only one pill per day for a certain drug, we may limit coverage for your prescription

to no more than one pill per day.

Section 4.3 Do any of these restrictions apply to your drugs?

The plan’s Drug List includes information about the restrictions described above. To find out if

any of these restrictions apply to a drug you take or want to take, check the Drug List. For the

most up-to-date information, call Member Services (phone numbers are printed on the back

cover of this booklet) or check our website (www.metroplusmedicare.org).

If there is a restriction for your drug, it usually means that you or your provider will have

to take extra steps in order for us to cover the drug. If there is a restriction on the drug you

want to take, you should contact Member Services to learn what you or your provider would

need to do to get coverage for the drug. If you want us to waive the restriction for you, you will

need to use the coverage decision process and ask us to make an exception. We may or may not

agree to waive the restriction for you. (See Chapter 9, Section 7.2 for information about asking

for exceptions.)




SECTION 5 What if one of your drugs is not covered in the way you’d like it to be covered?

Section 5.1 There are things you can do if your drug is not covered in the way you’d like it to be covered

We hope that your drug coverage will work well for you. But it’s possible that there could be a prescription drug you are currently taking, or one that you and your provider think you should be

taking, that is not on our formulary or is on our formulary with restrictions. For example:

• The drug might not be covered at all. Or maybe a generic version of the drug is covered

but the brand name version you want to take is not covered.

• The drug is covered, but there are extra rules or restrictions on coverage for that drug. As

explained in Section 4, some of the drugs covered by the plan have extra rules to restrict

their use. For example, you might be required to try a different drug first, to see if it will

work, before the drug you want to take will be covered for you. Or there might be limits

on what amount of the drug (number of pills, etc.) is covered during a particular time

period. In some cases, you may want us to waive the restriction for you.

• The drug is covered, but it is in a cost-sharing tier that makes your cost-sharing more

expensive than you think it should be. The plan puts each covered drug into one of two

different cost-sharing tiers. How much you pay for your prescription depends in part on

which cost-sharing tier your drug is in.

There are things you can do if your drug is not covered in the way that you’d like it to be

covered. Your options depend on what type of problem you have:

• If your drug is not on the Drug List or if your drug is restricted, go to Section 5.2 to learn

what you can do.

• If your drug is in a cost-sharing tier that makes your cost more expensive than you think

it should be, go to Section 5.3 to learn what you can do.

Section 5.2 What can you do if your drug is not on the Drug List or if the drug is restricted in some way?

If your drug is not on the Drug List or is restricted, here are things you can do:

• You may be able to get a temporary supply of the drug (only members in certain

situations can get a temporary supply). This will give you and your provider time to

change to another drug or to file a request to have the drug covered.

• You can change to another drug.

• You can request an exception and ask the plan to cover the drug or remove restrictions

from the drug.



You may be able to get a temporary supply

Under certain circumstances, the plan can offer a temporary supply of a drug to you when your

drug is not on the Drug List or when it is restricted in some way. Doing this gives you time to

talk with your provider about the change in coverage and figure out what to do.

To be eligible for a temporary supply, you must meet the two requirements below:

1. The change to your drug coverage must be one of the following types of changes:

• The drug you have been taking is no longer on the plan’s Drug List.

• -- or -- the drug you have been taking is now restricted in some way (Section 4 in this

chapter tells about restrictions).

2. You must be in one of the situations described below:

• For those members who are new or who were in the plan last year:

We will cover a temporary supply of your drug during the first 90 days of your

membership in the plan if you were new and during the first 90 days of the calendar

year if you were in the plan last year. This temporary supply will be for a maximum of

30 days. If your prescription is written for fewer days, we will allow multiple fills to

provide up to a maximum of 30 days of medication. The prescription must be filled at a

network pharmacy. (Please note that the long-term care pharmacy may provide the drug

in smaller amounts at a time to prevent waste.)

• For those members who have been in the plan for more than 90 days and reside in a

long-term care (LTC) facility and need a supply right away:

We will cover one 34-day supply of a particular drug, or less if your prescription is

written for fewer days. This is in addition to the above temporary supply situation.

• For those members who have been in the plan for more than 90 days and have a

change in level of care and need a supply right away:

We will cover one 34-day supply of a particular drug, or less if your prescription is

written for fewer days. This is in addition to the above temporary supply situation.

To ask for a temporary supply, call Member Services (phone numbers are printed on the back

cover of this booklet).

During the time when you are getting a temporary supply of a drug, you should talk with your

provider to decide what to do when your temporary supply runs out. You can either switch to a

different drug covered by the plan or ask the plan to make an exception for you and cover your

current drug. The sections below tell you more about these options.



You can change to another drug

Start by talking with your provider. Perhaps there is a different drug covered by the plan that

might work just as well for you. You can call Member Services to ask for a list of covered drugs

that treat the same medical condition. This list can help your provider find a covered drug that

might work for you. (Phone numbers for Member Services are printed on the back cover of this

booklet.)

You can ask for an exception

You and your provider can ask the plan to make an exception for you and cover the drug in the

way you would like it to be covered. If your provider says that you have medical reasons that

justify asking us for an exception, your provider can help you request an exception to the rule.

For example, you can ask the plan to cover a drug even though it is not on the plan’s Drug List.

Or you can ask the plan to make an exception and cover the drug without restrictions.

If you are a current member and a drug you are taking will be removed from the formulary or

restricted in some way for next year, we will allow you to request a formulary exception in

advance for next year. We will tell you about any change in the coverage for your drug for next

year. You can ask for an exception before next year and we will give you an answer within 72

hours after we receive your request (or your prescriber’s supporting statement). If we approve your request, we will authorize the coverage before the change takes effect.

If you and your provider want to ask for an exception, Chapter 9, Section 7.4 tells what to do. It

explains the procedures and deadlines that have been set by Medicare to make sure your request

is handled promptly and fairly.

Section 5.3 What can you do if your drug is in a cost-sharing tier you think is too high?

If your drug is in a cost-sharing tier you think is too high, here are things you can do:

You can change to another drug

If your drug is in a cost-sharing tier you think is too high, start by talking with your provider.

Perhaps there is a different drug in a lower cost-sharing tier that might work just as well for you.

You can call Member Services to ask for a list of covered drugs that treat the same medical

condition. This list can help your provider find a covered drug that might work for you. (Phone

numbers for Member Services are printed on the back cover of this booklet.)

You can ask for an exception

You and your provider can ask the plan to make an exception in the cost-sharing tier for the drug

so that you pay less for it. If your provider says that you have medical reasons that justify asking

us for an exception, your provider can help you request an exception to the rule.



If you and your provider want to ask for an exception, Chapter 9, Section 7.4 tells what to do. It

explains the procedures and deadlines that have been set by Medicare to make sure your request

is handled promptly and fairly.

SECTION 6 What if your coverage changes for one of your drugs?

Section 6.1 The Drug List can change during the year

Most of the changes in drug coverage happen at the beginning of each year (January 1).

However, during the year, the plan might make changes to the Drug List. For example, the plan

might:

• Add or remove drugs from the Drug List. New drugs become available, including new

generic drugs. Perhaps the government has given approval to a new use for an existing

drug. Sometimes, a drug gets recalled and we decide not to cover it. Or we might remove

a drug from the list because it has been found to be ineffective.

• Move a drug to a higher or lower cost-sharing tier.

• Add or remove a restriction on coverage for a drug (for more information about

restrictions to coverage, see Section 4 in this chapter).

• Replace a brand name drug with a generic drug.

We must follow Medicare requirements before we change the plan’s Drug List.

Section 6.2 What happens if coverage changes for a drug you are taking?

Information on changes to drug coverage

When changes to the Drug List occur during the year, we post information on our website about

those changes. We will update our online Drug List on a regularly scheduled basis to include any

changes that have occurred after the last update. Below we point out the times that you would get

direct notice if changes are made to a drug that you are then taking. You can also call Member

Services for more information (phone numbers are printed on the back cover of this booklet).

Do changes to your drug coverage affect you right away?

Changes that can affect you this year: In the below cases, you will be affected by the coverage

changes during the current year:

• A new generic drug replaces a brand name drug on the Drug List (or we change the

cost-sharing tier or add new restrictions to the brand name drug)



o We may immediately remove a brand name drug on our Drug List if we are

replacing it with a new generic drug that will appear on the same or lower cost

sharing tier and with the same or fewer restrictions. Also, when adding the new

generic drug, we may decide to keep the brand name drug on our Drug List, but

immediately move it to a different cost-sharing tier or add new restrictions.

o We may not tell you in advance before we make that change—even if you are

currently taking the brand name drug

o You or your prescriber can ask us to make an exception and continue to cover the

brand name drug for you. For information on how to ask for an exception, see

o Chapter 9 (What to do if you have a problem or complaint (coverage decisions,

appeals, complaints)).

o

o If you are taking the brand name drug at the time we make the change, we will

provide you with information about the specific change(s) we made. This will

also include information on the steps you may take to request an exception to

cover the brand name drug. You may not get this notice before we make the

change.

• Unsafe drugs and other drugs on the Drug List that are withdrawn from the market

o Once in a while, a drug may be suddenly withdrawn because it has been found to

be unsafe or removed from the market for another reason. If this happens, we will

immediately remove the drug from the Drug List. If you are taking that drug, we

will let you know of this change right away.

o Your prescriber will also know about this change, and can work with you to find

another drug for your condition.

• Other changes to drugs on the Drug List

o We may make other changes once the year has started that affect drugs you are

taking. For instance, we might add a generic drug that is not new to the market to

replace a brand name drug or change the cost-sharing tier or add new restrictions

to the brand name drug. We also might make changes based on FDA boxed

warnings or new clinical guidelines recognized by Medicare. We must give you at

least 30 days’ notice or give you a 30-day refill of the drug you are taking at a

network pharmacy.

o During this 30-day period, you should be working with your prescriber to switch

to a different drug that we cover.

o Or you or your prescriber can ask us to make an exception and continue to cover

the drug for you. For information on how to ask for an exception, see Chapter 9

(What to do if you have a problem or complaint (coverage decisions, appeals,

complaints).

Changes to drugs on the Drug List that will not affect people currently taking the drug: For

changes to the Drug List that are not described above, if you are currently taking the drug the



following types of changes will not affect you until January 1 of the next year if you stay in the

plan:

• If we move your drug into a higher cost-sharing tier

• If we put a new restriction on your use of the drug

• If we remove your drug from the Drug List

If any of these changes happen for a drug you are taking (but not because of a market

withdrawal, a generic drug replacing a brand name drug, or other change noted in the sections

above), then the change won’t affect your use or what you pay as your share of the cost until

January 1 of the next year. Until that date, you probably won’t see any increase in your payments

or any added restriction to your use of the drug. You will not get direct notice this year about

changes that do not affect you. However, on January 1 of the next year, the changes will affect

you, and it is important to check the new year’s Drug List for any changes to drugs.

SECTION 7 What types of drugs are not covered by the plan?

Section 7.1 Types of drugs we do not cover

This section tells you what kinds of prescription drugs are “excluded.” This means Medicare

does not pay for these drugs.

We won’t pay for the drugs that are listed in this section. The only exception: If the requested

drug is found upon appeal to be a drug that is not excluded under Part D and we should have paid

for or covered it because of your specific situation. (For information about appealing a decision

we have made to not cover a drug, go to Chapter 9, Section 7.5 in this booklet.) If the drug

excluded by our plan is also excluded by Medicaid, you must pay for it yourself.

Here are three general rules about drugs that Medicare drug plans will not cover under Part D:

• Our plan’s Part D drug coverage cannot cover a drug that would be covered under

Medicare Part A or Part B.

• Our plan cannot cover a drug purchased outside the United States and its territories.

• Our plan usually cannot cover off-label use. “Off-label use” is any use of the drug other than those indicated on a drug’s label as approved by the Food and Drug Administration.

o Generally, coverage for “off-label use” is allowed only when the use is supported

by certain reference books. These reference books are the American Hospital

Formulary Service Drug Information; the DRUGDEX Information System; and

for cancer, the National Comprehensive Cancer Network and Clinical

Pharmacology or their successors. If the use is not supported by any of these

reference books, then our plan cannot cover its “off-label use.”



Also, by law, the categories of drugs listed below are not covered by Medicare However, some

of these drugs may be covered for you under your Medicaid drug coverage. For additional

information on drugs covered by Medicaid, contact the New York Medicaid CHOICE Hotline at

1-800-505- 5678.

• Non-prescription drugs (also called over-the-counter drugs)

• Drugs when used to promote fertility

• Drugs when used for the relief of cough or cold symptoms

• Drugs when used for cosmetic purposes or to promote hair growth

• Prescription vitamins and mineral products, except prenatal vitamins and fluoride

preparations

• Drugs when used for the treatment of sexual or erectile dysfunction

• Drugs when used for treatment of anorexia, weight loss, or weight gain

• Outpatient drugs for which the manufacturer seeks to require that associated tests or

monitoring services be purchased exclusively from the manufacturer as a condition of

sale

SECTION 8 Show your plan membership card when you fill a prescription

Section 8.1 Show your membership card

To fill your prescription, show your plan membership card at the network pharmacy you choose.

When you show your plan membership card, the network pharmacy will automatically bill the

plan for our share of the costs of your covered prescription drug. You will need to pay the

pharmacy your share of the cost when you pick up your prescription.

For Medicaid covered drugs, show your Medicaid card to fill your prescription.

Section 8.2 What if you don’t have your membership card with you?

If you don’t have your plan membership card with you when you fill your prescription, ask the pharmacy to call the plan to get the necessary information.

If the pharmacy is not able to get the necessary information, you may have to pay the full cost

of the prescription when you pick it up. (You can then ask us to reimburse you for our share.

See Chapter 7, Section 2.1 for information about how to ask the plan for reimbursement.)

We are not allowed to reimburse you for benefits covered by Medicaid.



SECTION 9 Part D drug coverage in special situations

Section 9.1 What if you’re in a hospital or a skilled nursing facility for a stay that is covered by the plan?

If you are admitted to a hospital or to a skilled nursing facility for a stay covered by the plan, we

will generally cover the cost of your prescription drugs during your stay. Once you leave the

hospital or skilled nursing facility, the plan will cover your drugs as long as the drugs meet all of

our rules for coverage. See the previous parts of this section that tell about the rules for getting

drug coverage. Chapter 6 (What you pay for your Part D prescription drugs) gives more

information about drug coverage and what you pay.

Section 9.2 What if you’re a resident in a long-term care (LTC) facility?

Usually, a long-term care (LTC) facility (such as a nursing home) has its own pharmacy, or a

pharmacy that supplies drugs for all of its residents. If you are a resident of a long-term care

facility, you may get your prescription drugs through the facility’s pharmacy as long as it is part

of our network.

Check your Pharmacy Directory to find out if your long-term care facility’s pharmacy is part of

our network. If it isn’t, or if you need more information, please contact Member Services (phone


What if you’re a resident in a long-term care (LTC) facility and become a new member of the plan?

If you need a drug that is not on our Drug List or is restricted in some way, the plan will cover a

temporary supply of your drug during the first 90 days of your membership. The total supply

will be for a maximum of a 34-day supply, or less if your prescription is written for fewer days.

(Please note that the long-term care pharmacy may provide the drug in smaller amounts at a time

to prevent waste.) If you have been a member of the plan for more than 90 days and need a drug

that is not on our Drug List or if the plan has any restriction on the drug’s coverage, we will cover one 34-day supply, or less if your prescription is written for fewer days.

During the time when you are getting a temporary supply of a drug, you should talk with your

provider to decide what to do when your temporary supply runs out. Perhaps there is a different

drug covered by the plan that might work just as well for you. Or you and your provider can ask

the plan to make an exception for you and cover the drug in the way you would like it to be

covered. If you and your provider want to ask for an exception, Chapter 9, Section 7.4 tells what

to do.



Section 9.3 What if you’re also getting drug coverage from an employer or retiree group plan?

Do you currently have other prescription drug coverage through your (or your spouse’s) employer or retiree group? If so, please contact that group’s benefits administrator. He or she

can help you determine how your current prescription drug coverage will work with our plan.

In general, if you are currently employed, the prescription drug coverage you get from us will be

secondary to your employer or retiree group coverage. That means your group coverage would

pay first.

Special note about ‘creditable coverage’:

Each year your employer or retiree group should send you a notice that tells if your prescription

drug coverage for the next calendar year is “creditable” and the choices you have for drug

coverage.

If the coverage from the group plan is “creditable,” it means that the plan has drug coverage that

is expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage.

Keep these notices about creditable coverage, because you may need them later. If you enroll

in a Medicare plan that includes Part D drug coverage, you may need these notices to show that

you have maintained creditable coverage. If you didn’t get a notice about creditable coverage from your employer or retiree group plan, you can get a copy from your employer or retiree

plan’s benefits administrator or the employer or union.

Section 9.4 What if you’re in Medicare-certified hospice?

Drugs are never covered by both hospice and our plan at the same time. If you are enrolled in

Medicare hospice and require an anti-nausea, laxative, pain medication or antianxiety drug that is

not covered by your hospice because it is unrelated to your terminal illness and related

conditions, our plan must receive notification from either the prescriber or your hospice provider

that the drug is unrelated before our plan can cover the drug. To prevent delays in receiving any

unrelated drugs that should be covered by our plan, you can ask your hospice provider or

prescriber to make sure we have the notification that the drug is unrelated before you ask a

pharmacy to fill your prescription.

In the event you either revoke your hospice election or are discharged from hospice, our plan

should cover all your drugs. To prevent any delays at a pharmacy when your Medicare hospice

benefit ends, you should bring documentation to the pharmacy to verify your revocation or

discharge. See the previous parts of this section that tell about the rules for getting drug coverage

under Part D Chapter 6 (What you pay for your Part D prescription drugs) gives more

information about drug coverage and what you pay.



SECTION 10 Programs on drug safety and managing medications

Section 10.1 Programs to help members use drugs safely

We conduct drug use reviews for our members to help make sure that they are getting safe and

appropriate care. These reviews are especially important for members who have more than one

provider who prescribes their drugs.

We do a review each time you fill a prescription. We also review our records on a regular basis.

During these reviews, we look for potential problems such as:

• Possible medication errors

• Drugs that may not be necessary because you are taking another drug to treat the same

medical condition

• Drugs that may not be safe or appropriate because of your age or gender

• Certain combinations of drugs that could harm you if taken at the same time

• Prescriptions written for drugs that have ingredients you are allergic to

• Possible errors in the amount (dosage) of a drug you are taking

If we see a possible problem in your use of medications, we will work with your provider to

correct the problem.

Section 10.2 Drug Management Program (DMP) to help members safely use their opioid medications

We have a program that can help make sure our members safely use their prescription opioid

medications, or other medications that are frequently abused. This program is called a Drug

Management Program (DMP). If you use opioid medications that you get from several doctors or

pharmacies, we may talk to your doctors to make sure your use is appropriate and medically

necessary. Working with your doctors, if we decide you are at risk for misusing or abusing your

opioid or benzodiazepine medications, we may limit how you can get those medications. The

limitations may be:

• Requiring you to get all your prescriptions for opioid or benzodiazepine medications

from one pharmacy

• Requiring you to get all your prescriptions for opioid or benzodiazepine medications

from one doctor

• Limiting the amount of opioid or benzodiazepine medications we will cover for you

If we decide that one or more of these limitations should apply to you, we will send you a letter

in advance. The letter will have information explaining the terms of the limitations with think

should apply to you. You will also have an opportunity to tell us which doctors or pharmacies

you prefer to use. If you think we made a mistake or you disagree with our determination that



you are at-risk for prescription drug abuse or the limitation, you and your prescriber have the

right to ask us for an appeal. See Chapter 9 for information about how to ask for an appeal.

The DMP may not apply to you if you have certain medical conditions, such as cancer, or you

are receiving hospice care or live in a long-term care facility.

Section 10.3 Medication Therapy Management (MTM) program to help members manage their medications

We have a program that can help our members with complex health needs. For example, some

members have several medical conditions, take different drugs at the same time, and have high

drug costs.

This program is voluntary and free to members. A team of pharmacists and doctors developed

the program for us. This program can help make sure that our members get the most benefit from

the drugs they take. Our program is called a Medication Therapy Management (MTM) program.

Some members who take medications for different medical conditions may be able to get

services through an MTM program. A pharmacist or other health professional will give you a

comprehensive review of all your medications. You can talk about how best to take your

medications, your costs, and any problems or questions you have about your prescription and

over-the-counter medications. You’ll get a written summary of this discussion. The summary has

a medication action plan that recommends what you can do to make the best use of your

medications, with space for you to take notes or write down any follow-up questions. You’ll also

get a personal medication list that will include all the medications you’re taking and why you

take them.

It’s a good idea to have your medication review before your yearly “Wellness” visit, so you can

talk to your doctor about your action plan and medication list. Bring your action plan and

medication list with you to your visit or anytime you talk with your doctors, pharmacists, and

other health care providers. Also, keep your medication list with you (for example, with your ID)

in case you go to the hospital or emergency room.

If we have a program that fits your needs, we will automatically enroll you in the program and

send you information. If you decide not to participate, please notify us and we will withdraw you

from the program. If you have any questions about these programs, please contact Member


CHAPTER 6

What you pay for your Part D prescription drugs


Chapter 6. What you pay for your Part D prescription drugs



Section 1.1 Use this chapter together with other materials that explain your drug

coverage....................................................................................................... 128

Section 1.2 Types of out-of-pocket costs you may pay for covered drugs .................... 129

SECTION 2 What you pay for a drug depends on which “drug payment stage” you are in when you get the drug ..................................... 129

Section 2.1 What are the drug payment stages for MetroPlus Advantage Plan (HMO

SNP) members?........................................................................................... 129

SECTION 3 We send you reports that explain payments for your drugs and which payment stage you are in ............................................ 130

Section 3.1 We send you a monthly report called the “Part D Explanation of Benefits” (the “Part D EOB”) ..................................................................... 130

Section 3.2 Help us keep our information about your drug payments up to date .......... 131

SECTION 4 During the Deductible Stage, you pay the full cost of your drugs ............................................................................................... 132

Section 4.1 You stay in the Deductible Stage until you have paid $0 or $85 for your

drugs ............................................................................................................ 132

SECTION 5 During the Initial Coverage Stage, the plan pays its share of your drug costs and you pay your share ..................................... 132

Section 5.1 What you pay for a drug depends on the drug and where you fill your

prescription.................................................................................................. 132

Section 5.2 A table that shows your costs for a one-month supply of a drug ................ 133

Section 5.3 If your doctor prescribes less than a full month’s supply, you may not

have to pay the cost of the entire month’s supply ....................................... 134

Section 5.4 A table that shows your costs for a long-term (up to a 90-day) supply of a

drug.............................................................................................................. 135

Section 5.5 You stay in the Initial Coverage Stage until your out-of-pocket costs for

the year reach $5,100................................................................................... 136

Section 5.6 How Medicare calculates your out-of-pocket costs for prescription drugs. 137

SECTION 6 There is no coverage gap for MetroPlus Advantage Plan (HMO SNP) ...................................................................................... 139

Section 6.1 You do not have a coverage gap for your Part D drugs. ............................. 139



SECTION 7 During the Catastrophic Coverage Stage, the plan pays most of the costs for your drugs .................................................. 139

Section 7.1 Once you are in the Catastrophic Coverage Stage, you will stay in this

stage for the rest of the year ........................................................................ 139

SECTION 8 What you pay for vaccinations covered by Part D depends on how and where you get them ................................................... 140

Section 8.1 Our plan may have separate coverage for the Part D vaccine medication

itself and for the cost of giving you the vaccine.......................................... 140

Section 8.2 You may want to call us at Member Services before you get a vaccination141



How can you get information about your drug costs if you’re receiving

“Extra Help” with your Part D prescription drug costs?

Most of our members qualify for and are getting “Extra Help” from Medicare to pay for their prescription drug plan costs. If you are in the “Extra Help” program, some

information in this Evidence of Coverage about the costs for Part D prescription

drugs may not apply to you. We sent you a separate insert, called the “Evidence of

Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” (also

known as the “Low Income Subsidy Rider” or the “LIS Rider”), which tells you about

your drug coverage. If you don’t have this insert, please call Member Services and ask

for the “LIS Rider.” (Phone numbers for Member Services are printed on the back cover

of this booklet.)


Section 1.1 Use this chapter together with other materials that explain your drug coverage

This chapter focuses on what you pay for your Part D prescription drugs. To keep things simple,

we use “drug” in this chapter to mean a Part D prescription drug. As explained in Chapter 5, not

all drugs are Part D drugs – some drugs are excluded from Part D coverage by law. Some of the

drugs excluded from Part D coverage are covered under Medicare Part A or Part B or under

Medicaid.

To understand the payment information we give you in this chapter, you need to know the basics

of what drugs are covered, where to fill your prescriptions, and what rules to follow when you

get your covered drugs. Here are materials that explain these basics:

• The plan’s List of Covered Drugs (Formulary). To keep things simple, we call this the

“Drug List.”

o This Drug List tells which drugs are covered for you.

o It also tells which of the two “cost-sharing tiers” the drug is in and whether there are any restrictions on your coverage for the drug.

o If you need a copy of the Drug List, call Member Services (phone numbers are

printed on the back cover of this booklet). You can also find the Drug List on our

website at www.metroplusmedicare.org. The Drug List on the website is always

the most current.

• Chapter 5 of this booklet. Chapter 5 gives the details about your prescription drug

coverage, including rules you need to follow when you get your covered drugs. Chapter 5

also tells which types of prescription drugs are not covered by our plan.

• The plan’s Provider/Pharmacy Directory. In most situations you must use a network

pharmacy to get your covered drugs (see Chapter 5 for the details). The

Provider/Pharmacy Directory has a list of pharmacies in the plan’s network. It also tells




you which pharmacies in our network can give you a long-term supply of a drug (such as

filling a prescription for a three-month’s supply).

Section 1.2 Types of out-of-pocket costs you may pay for covered drugs

To understand the payment information we give you in this chapter, you need to know about the

types of out-of-pocket costs you may pay for your covered services. The amount that you pay for

a drug is called “cost-sharing,” and there are three ways you may be asked to pay.

• The “deductible” is the amount you must pay for drugs before our plan begins to pay its

share.

• “Copayment” means that you pay a fixed amount each time you fill a prescription.

• “Coinsurance” means that you pay a percent of the total cost of the drug each time you

fill a prescription.

SECTION 2 What you pay for a drug depends on which “drug payment stage” you are in when you get the drug

Section 2.1 What are the drug payment stages for MetroPlus Advantage Plan (HMO SNP) members?

As shown in the table below, there are “drug payment stages” for your Medicare Part D prescription drug coverage under MetroPlus Advantage Plan (HMO SNP). How much you pay

for a drug depends on which of these stages you are in at the time you get a prescription filled

or refilled. Keep in mind you are always responsible for the plan’s monthly premium

regardless of the drug payment stage.



Stage 1 Yearly Deductible

Stage

Stage 2 Initial Coverage

Stage

Stage 3 Coverage Gap

Stage

Stage 4 Catastrophic

Coverage Stage

If you receive “Extra Help” to pay your prescription drugs, your deductible amount will be either $0 or $85, depending on the level of “Extra Help” you receive. (Look at the separate insert, the “LIS Rider,” for your deductible amount.)

If your deductible is $0: This payment stage does not apply to you.

If your deductible is $85: You pay the full cost of your drugs until you have paid $85 for your drugs.

(Details are in Section 4 of this chapter.)

During this stage, the plan pays its share of the cost of your drugs and you pay your share of the cost.

After you (or others on your behalf) have met your deductible, the plans pays its share of the costs of your drugs and you pay your share.

You stay in this stage until your year-to-date “out-of-pocket costs” (your payments) reach $5,100.


Because there is no coverage gap for the plan, this payment stage does not apply to you.

During this stage, the plan will pay most of the costs of your drugs for the rest of the calendar year (through December 31, 2019).


SECTION 3 We send you reports that explain payments for your drugs and which payment stage you are in

Section 3.1 We send you a monthly report called the “Part D Explanation of Benefits” (the “Part D EOB”)

Our plan keeps track of the costs of your prescription drugs and the payments you have made

when you get your prescriptions filled or refilled at the pharmacy. This way, we can tell you

when you have moved from one drug payment stage to the next. In particular, there are two types

of costs we keep track of:

• We keep track of how much you have paid. This is called your “out-of-pocket” cost.

• We keep track of your “total drug costs.” This is the amount you pay out-of-pocket or

others pay on your behalf plus the amount paid by the plan.

Our plan will prepare a written report called the Part D Explanation of Benefits (it is sometimes

called the “Part D EOB”) when you have had one or more prescriptions filled through the plan

during the previous month. It includes:

• Information for that month. This report gives the payment details about the

prescriptions you have filled during the previous month. It shows the total drug costs,

what the plan paid, and what you and others on your behalf paid.



• Totals for the year since January 1. This is called “year-to-date” information. It shows

you the total drug costs and total payments for your drugs since the year began.

Section 3.2 Help us keep our information about your drug payments up to date

To keep track of your drug costs and the payments you make for drugs, we use records we get

from pharmacies. Here is how you can help us keep your information correct and up to date:

• Show your membership card when you get a prescription filled. To make sure we

know about the prescriptions you are filling and what you are paying, show your plan

membership card every time you get a prescription filled.

• Make sure we have the information we need. There are times you may pay for

prescription drugs when we will not automatically get the information we need to

keep track of your out-of-pocket costs. To help us keep track of your out-of-pocket costs,

you may give us copies of receipts for drugs that you have purchased. (If you are billed

for a covered drug, you can ask our plan to pay our share of the cost for the drug. For

instructions on how to do this, go to Chapter 7, Section 2 of this booklet.) We are not

allowed to reimburse you for benefits covered by Medicaid. Here are some types of

situations when you may want to give us copies of your drug receipts to be sure we have

a complete record of what you have spent for your drugs:

o When you purchase a covered drug at a network pharmacy at a special price or

using a discount card that is not part of our plan’s benefit

o When you made a copayment for drugs that are provided under a drug

manufacturer patient assistance program

o Any time you have purchased covered drugs at out-of-network pharmacies or

other times you have paid the full price for a covered drug under special

circumstances

• Send us information about the payments others have made for you. Payments made

by certain other individuals and organizations also count toward your out-of-pocket costs

and help qualify you for catastrophic coverage. For example, payments made by a State

Pharmaceutical Assistance Program, an AIDS drug assistance program (ADAP), the

Indian Health Service, and most charities count toward your out-of-pocket costs. You

should keep a record of these payments and send them to us so we can track your costs.

• Check the written report we send you. When you receive a Part D Explanation of

Benefits (a Part D EOB) in the mail, please look it over to be sure the information is

complete and correct. If you think something is missing from the report, or you have any

questions, please call us at Member Services (phone numbers are printed on the back

cover of this booklet). Be sure to keep these reports. They are an important record of your

drug expenses.



SECTION 4 During the Deductible Stage, you pay the full cost of your drugs

Section 4.1 You stay in the Deductible Stage until you have paid $0 or $85 for your drugs

Most of our members get “Extra Help” with their prescription drug costs, so the Deductible

Stage does not apply to many of them. If you receive “Extra Help,” your deductible amount

depends on the level of “Extra Help” you receive – you will either:

• Not pay a deductible

• --or-- Pay a deductible of $85.

Look at the separate insert (the “LIS Rider”) for information about your deductible amount.

If you do not receive “Extra Help,” the Deductible Stage is the first payment stage for your drug

coverage. This stage begins when you fill your first prescription in the year. When you are in this

payment stage, you must pay the full cost of your drugs until you reach the plan’s deductible

amount, which is $85 for 2019.

• Your “full cost” is usually lower than the normal full price of the drug, since our plan has

negotiated lower costs for most drugs.

• The “deductible” is the amount you must pay for your Part D prescription drugs before

the plan begins to pay its share.

Once you have paid $85 for your drugs, you leave the Deductible Stage and move on to the next

drug payment stage, which is the Initial Coverage Stage.

SECTION 5 During the Initial Coverage Stage, the plan pays its share of your drug costs and you pay your share

Section 5.1 What you pay for a drug depends on the drug and where you fill your prescription

During the Initial Coverage Stage, the plan pays its share of the cost of your covered prescription

drugs, and you pay your share (your coinsurance amount). Your share of the cost will vary

depending on the drug and where you fill your prescription.



The plan has two cost-sharing tiers

Every drug on the plan’s Drug List is in one of two cost-sharing tiers. In general, the higher the

cost-sharing tier number, the higher your cost for the drug:

• Cost-Sharing Tier 1 includes generic drugs (including brand drugs treated as generic).

This is the lowest tier.

• Cost Sharing Tier 2 includes all other drugs. This is the highest tier.

To find out which cost-sharing tier your drug is in, look it up in the plan’s Drug List.

Your pharmacy choices

How much you pay for a drug depends on whether you get the drug from:

• A retail pharmacy that is in our plan’s network

• A pharmacy that is not in the plan’s network

• The plan’s mail-order pharmacy

For more information about these pharmacy choices and filling your prescriptions, see Chapter 5

in this booklet and the plan’s Pharmacy Directory.

Section 5.2 A table that shows your costs for a one-month supply of a drug

During the Initial Coverage Stage, your share of the cost of a covered drug will be either a

copayment or coinsurance.

• “Copayment” means that you pay a fixed amount each time you fill a prescription.

• “Coinsurance” means that you pay a percent of the total cost of the drug each time you

fill a prescription.

As shown in the table below, the amount of the copayment or coinsurance depends on which

cost-sharing tier your drug is in. Please note:

• If your covered drug costs less than the copayment amount listed in the chart, you will

pay that lower price for the drug. You pay either the full price of the drug or the

copayment amount, whichever is lower.

• We cover prescriptions filled at out-of-network pharmacies in only limited situations.

Please see Chapter 5, Section 2.5 for information about when we will cover a

prescription filled at an out-of-network pharmacy.



Your share of the cost when you get a one-month supply of a covered Part D prescription drug:

Tier

Standard retail

cost-sharing (in-

network)

(up to a 30-day

supply)

Mail-order

cost-sharing

(up to a 30-day

supply)

Long-term

care (LTC)

cost-sharing

(up to a 34-day

supply)

Out-of-network cost-

sharing

(Coverage is limited

to certain situations;

see Chapter 5 for

details.) (up to a 30-

day supply)

Cost-Sharing

Tier 1

(generic

drugs,

including

brand drugs

treated as

generics)

Depending on

your

income and level

of

Medicaid

eligibility,

you pay the

following cost

sharing amounts:-

$0 copay

- $1.25 copay

- $3.40 copay

- Up to a 15%

coinsurance

Depending on

your

income and

level of

Medicaid

eligibility,

you pay the

following cost

sharing

amounts:- $0

copay

- $1.25 copay

- $3.40 copay

- Up to a 15%

coinsurance

Depending on

your

income and

level of

Medicaid

eligibility,

you pay the

following cost

sharing

amounts:- $0

copay

- $1.25 copay

- $3.40 copay

- Up to a 15%

coinsurance

Depending on your

income and level of

Medicaid eligibility,

you pay the following

cost sharing amounts:-

$0 copay

- $1.25 copay

- $3.40 copay

- Up to a 15%

coinsurance

Cost-Sharing

Tier 2

(all other

drugs)

Depending on

your

income and level

of

Medicaid

eligibility,

you pay the

following cost

sharing amounts:-

$0 copay

- $3.80 copay

- $8.50 copay

- Up to a 15%

coinsurance

Depending on

your

income and

level of

Medicaid

eligibility,

you pay the

following cost

sharing

amounts:- $0

copay

- $3.80 copay

- $8.50 copay

- Up to a 15%

coinsurance

Depending on

your

income and

level of

Medicaid

eligibility,

you pay the

following cost

sharing

amounts:- $0

copay

- $3.80 copay

- $8.50 copay

- Up to a 15%

coinsurance

Depending on your

income and level of


you pay the following

cost sharing amounts:-

$0 copay

- $3.80 copay

- $8.50 copay

- Up to a 15%

coinsurance

Section 5.3 If your doctor prescribes less than a full month’s supply, you may not have to pay the cost of the entire month’s supply

Typically, the amount you pay for a prescription drug covers a full month’s supply of a covered

drug. However, your doctor can prescribe less than a month’s supply of drugs. There may be times when you want to ask your doctor about prescribing less than a month’s supply of a drug



(for example, when you are trying a medication for the first time that is known to have serious

side effects). If your doctor prescribes less than a full month’s supply, you will not have to pay

for the full month’s supply for certain drugs.

The amount you pay when you get less than a full month’s supply will depend on whether you

are responsible for paying coinsurance (a percentage of the total cost) or a copayment (a flat

dollar amount).

• If you are responsible for coinsurance, you pay a percentage of the total cost of the drug.

You pay the same percentage regardless of whether the prescription is for a full month’s

supply or for fewer days. However, because the entire drug cost will be lower if you get

less than a full month’s supply, the amount you pay will be less.

• If you are responsible for a copayment for the drug, your copay will be based on the

number of days of the drug that you receive. We will calculate the amount you pay per

day for your drug (the “daily cost-sharing rate”) and multiply it by the number of days of

the drug you receive.

o Here’s an example: Let’s say the copay for your drug for a full month’s supply (a 30-day supply) is $30. This means that the amount you pay per day for your drug

is $1. If you receive a 7 days’ supply of the drug, your payment will be $1 per day multiplied by 7 days, for a total payment of $7.

Daily cost-sharing allows you to make sure a drug works for you before you have to pay for an

entire month’s supply. You can also ask your doctor to prescribe, and your pharmacist to

dispense, less than a full month’s supply of a drug or drugs, if this will help you better plan refill

dates for different prescriptions so that you can take fewer trips to the pharmacy. The amount

you pay will depend upon the days’ supply you receive.

Section 5.4 A table that shows your costs for a long-term (up to a 90-day) supply of a drug

For some drugs, you can get a long-term supply (also called an “extended supply”) when you fill your prescription. A long-term supply is up to a 90-day supply. (For details on where and how to

get a long-term supply of a drug, see Chapter 5, Section 2.4.)

The table below shows what you pay when you get a long-term (up to a 90-day) supply of a

drug.



Your share of the cost when you get a long-term supply of a covered Part D prescription drug:

Tier

Standard retail cost-sharing

(in-network)

(up to a 90-day supply)

Mail-order cost-sharing

(90-day supply)

Cost-Sharing Tier 1

(generic drugs, including

brand drugs treated as

generic)

Depending on your

income and level of


you pay the following cost

sharing amounts:- $0 copay

- $1.25 copay

- $3.40 copay

- Up to a 15% coinsurance

Depending on your

income and level of




- $1.25 copay

- $3.40 copay


Cost-Sharing Tier 2

(all other drugs)

Depending on your

income and level of




- $3.80 copay

- $8.50 copay


Depending on your

income and level of




- $3.80 copay

- $8.50 copay


Section 5.5 You stay in the Initial Coverage Stage until your out-of-pocket costs for the year reach $5,100

You stay in the Initial Coverage Stage until your total out-of-pocket costs reach $5,100].

Medicare has rules about what counts and what does not count as your out-of-pocket costs. (See

Section 5.6 for information about how Medicare counts your out-of-pocket costs.) When you

reach an out-of-pocket limit of $5,100, you leave the Initial Coverage Gap and move on to the

Catastrophic Coverage Stage.

The Part D Explanation of Benefits (Part D EOB) that we send to you will help you keep track of

how much you and the plan, as well as any third parties, have spent on your behalf during the

year. Many people do not reach the $5,100 limit in a year.

We will let you know if you reach this $5,100amount. If you do reach this amount, you will

leave the Initial Coverage Stage and move on to the Catastrophic Coverage Stage.



Section 5.6 How Medicare calculates your out-of-pocket costs for prescription drugs

Medicare has rules about what counts and what does not count as your out-of-pocket costs.

When you reach an out-of-pocket limit of $5,100, you leave the Initial Coverage Stage and move

on to the Catastrophic Coverage Stage.

Here are Medicare’s rules that we must follow when we keep track of your out-of-pocket costs

for your drugs.

These payments are included in your out-of-pocket costs

When you add up your out-of-pocket costs, you can include the payments listed below (as

long as they are for Part D covered drugs and you followed the rules for drug coverage that

are explained in Chapter 5 of this booklet):

• The amount you pay for drugs when you are in any of the following drug payment

stages:

o The Deductible Stage

o The Initial Coverage Stage

• Any payments you made during this calendar year as a member of a different

Medicare prescription drug plan before you joined our plan

It matters who pays:

• If you make these payments yourself, they are included in your out-of-pocket costs.

• These payments are also included if they are made on your behalf by certain other

individuals or organizations. This includes payments for your drugs made by a

friend or relative, by most charities, by AIDS drug assistance programs, by a State

Pharmaceutical Assistance Program that is qualified by Medicare, or by the Indian

Health Service. Payments made by Medicare’s “Extra Help” Program are also

included.

Moving on to the Catastrophic Coverage Stage:

When you (or those paying on your behalf) have spent a total of $5,100 in out-of-pocket

costs within the calendar year, you will move from the Initial Coverage Stage to the




These payments are not included in your out-of-pocket costs

When you add up your out-of-pocket costs, you are not allowed to include any of these

types of payments for prescription drugs:

• The amount you pay for your monthly premium.

• Drugs you buy outside the United States and its territories.

• Drugs that are not covered by our plan.

• Drugs you get at an out-of-network pharmacy that do not meet the plan’s requirements

for out-of-network coverage.

• Drugs covered by Medicaid only.

• Non-Part D drugs, including prescription drugs covered by Part A or Part B and other

drugs excluded from coverage by Medicare.

• Payments you make toward prescription drugs not normally covered in a Medicare

Prescription Drug Plan.

• Payments made by the plan for your brand or generic drugs while in the Coverage Gap.

• Payments for your drugs that are made by group health plans including employer health

plans.

• Payments for your drugs that are made by certain insurance plans and government-

funded health programs such as TRICARE and Veterans Affairs.

• Payments for your drugs made by a third-party with a legal obligation to pay for

prescription costs (for example, workers’ compensation).

Reminder: If any other organization such as the ones listed above pays part or all of your

out-of-pocket costs for drugs, you are required to tell our plan. Call Member Services to let

us know (phone numbers are printed on the back cover of this booklet).

How can you keep track of your out-of-pocket total?

• We will help you. The Part D Explanation of Benefits (Part D EOB) report we send to

you includes the current amount of your out-of-pocket costs (Section 3 in this chapter

tells about this report). When you reach a total of $5,100 in out-of-pocket costs for the

year, this report will tell you that you have left the Initial Coverage Stage and have

moved on to the Catastrophic Coverage Stage.

• Make sure we have the information we need. Section 3.2 tells what you can do to help

make sure that our records of what you have spent are complete and up to date.



SECTION 6 There is no coverage gap for MetroPlus Advantage Plan (HMO SNP)

Section 6.1 You do not have a coverage gap for your Part D drugs.

There is no coverage gap for MetroPlus Advantage Plan (HMO SNP). Once you leave the Initial

Coverage Stage, you move on to the Catastrophic Coverage Stage. See Section 7 for information

about your coverage in the Catastrophic Coverage Stage.

SECTION 7 During the Catastrophic Coverage Stage, the plan pays most of the costs for your drugs

Section 7.1 Once you are in the Catastrophic Coverage Stage, you will stay in this stage for the rest of the year

You qualify for the Catastrophic Coverage Stage when your out-of-pocket costs have reached the

$5,100 limit for the calendar year. Once you are in the Catastrophic Coverage Stage, you will

stay in this payment stage until the end of the calendar year.

If you receive “Extra Help” to pay for your prescription drugs, your costs for covered drugs will

depend on the level of “Extra Help” you receive. During this stage, your share of the cost for a

covered drug will be either:

• $0; or

• A coinsurance or a copayment, whichever is the larger amount:

o – either – Coinsurance of 5% of the cost of the drug

o –or – $3.40 for a generic drug or a drug that is treated like a generic and $8.50 for

all other drugs.

o Our plan pays the rest of the cost.

Look at the separate insert (the “LIS Rider”) for information about your costs during the




SECTION 8 What you pay for vaccinations covered by Part D depends on how and where you get them

Section 8.1 Our plan may have separate coverage for the Part D vaccine medication itself and for the cost of giving you the vaccine

Our plan provides coverage of a number of Part D vaccines. We also cover vaccines that are

considered medical benefits. You can find out about coverage of these vaccines by going to the

Benefits Chart in Chapter 4, Section 2.1.

There are two parts to our coverage of Part D vaccinations:

• The first part of coverage is the cost of the vaccine medication itself. The vaccine is a

prescription medication.

• The second part of coverage is for the cost of giving you the vaccine. (This is sometimes

called the “administration” of the vaccine.)

What do you pay for a Part D vaccination?

What you pay for a Part D vaccination depends on three things:

1. The type of vaccine (what you are being vaccinated for).

o Some vaccines are considered medical benefits. You can find out about your

coverage of these vaccines by going to Chapter 4, Benefits Chart (what is covered

and what you pay).

o Other vaccines are considered Part D drugs. You can find these vaccines listed in

the plan’s List of Covered Drugs (Formulary).

2. Where you get the vaccine medication.

3. Who gives you the vaccine.

What you pay at the time you get the Part D vaccination can vary depending on the

circumstances. For example:

• Sometimes when you get your vaccine, you will have to pay the entire cost for both the

vaccine medication and for getting the vaccine. You can ask our plan to pay you back for

our share of the cost.

• Other times, when you get the vaccine medication or the vaccine, you will pay only your

share of the cost.

To show how this works, here are three common ways you might get a Part D vaccine.

Remember you are responsible for all of the costs associated with vaccines (including their

administration) during the Deductible and Coverage Gap Stage of your benefit.



Situation 1: You buy the Part D vaccine at the pharmacy and you get your vaccine at the

network pharmacy. (Whether you have this choice depends on where you live.

Some states do not allow pharmacies to administer a vaccination.)

• You will pay nothing to the pharmacy or have to pay the pharmacy the

amount of your copayment for the vaccine and the cost of giving you

the vaccine.

• Our plan will pay the remainder of the costs.

Situation 2: You get the Part D vaccination at your doctor’s office.

• When you get the vaccination, you will pay for the entire cost of the

vaccine and its administration.

• You can then ask our plan to pay you back for our share of the cost by

using the procedures that are described in Chapter 7 of this booklet

(Asking us to pay our share of a bill you have received for covered

medical services or drugs).

• You will be reimbursed the amount you paid less your normal

copayment for the vaccine (including administration) (If you get

“Extra Help,” we will reimburse you for this difference.).

Situation 3: You buy the Part D vaccine at your pharmacy, and then take it to your

doctor’s office where they give you the vaccine.

• You will pay nothing to the pharmacy for the vaccine itself or have to

pay the pharmacy the amount of your copayment for the vaccine itself.

• When your doctor gives you the vaccine, you will pay the entire cost

for this service. You can then ask our plan to pay you back for our

share of the cost by using the procedures described in Chapter 7 of this

booklet.

• You will be reimbursed the amount charged by the doctor for

administering the vaccine.

Section 8.2 You may want to call us at Member Services before you get a vaccination

The rules for coverage of vaccinations are complicated. We are here to help. We recommend that

you call us first at Member Services whenever you are planning to get a vaccination. (Phone

numbers for Member Services are printed on the back cover of this booklet.)

• We can tell you about how your vaccination is covered by our plan and explain your

share of the cost.

• We can tell you how to keep your own cost down by using providers and pharmacies in

our network.

• If you are not able to use a network provider and pharmacy, we can tell you what you

need to do to ask us to pay you back for our share of the cost.

CHAPTER 7

Asking us to pay our share of a bill you have received for covered

medical services or drugs


Chapter 7. Asking us to pay our share of a bill you have received for covered medical services or drugs


SECTION 1 Situations in which you should ask us to pay for your covered services or drugs............................................................. 144

Section 1.1 If you pay for your covered services or drugs, or if you receive a bill, you

can ask us for payment ................................................................................ 144

SECTION 2 How to ask us to pay you back or to pay a bill you have received........................................................................................... 146

Section 2.1 How and where to send us your request for payment ................................. 146

SECTION 3 We will consider your request for payment and say yes or no..................................................................................................... 147

Section 3.1 We check to see whether we should cover the service or drug and how

much we owe............................................................................................... 147

Section 3.2 If we tell you that we will not pay for all or part of the medical care or

drug, you can make an appeal ..................................................................... 147

SECTION 4 Other situations in which you should save your receipts and send copies to us.................................................................... 148

Section 4.1 In some cases, you should send copies of your receipts to us to help us

track your out-of-pocket drug costs............................................................. 148



SECTION 1 Situations in which you should ask us to pay for your covered services or drugs

Section 1.1 If you pay for your covered services or drugs, or if you receive a bill, you can ask us for payment

Our network providers bill the plan directly for your covered services and drugs. If you get a bill

for the full cost of medical care or drugs you have received, you should send this bill to us so that

we can pay it. When you send us the bill, we will look at the bill and decide whether the services

should be covered. If we decide they should be covered, we will pay the provider directly.

If you have already paid for services or drugs covered by the plan, you can ask our plan to pay

you back (paying you back is often called “reimbursing” you). It is your right to be paid back by our plan whenever you’ve paid more than your share of the cost for medical services or drugs

that are covered by our plan. When you send us a bill you have already paid, we will look at the

bill and decide whether the services or drugs should be covered. If we decide they should be

covered, we will pay you back for the services or drugs.

Here are examples of situations in which you may need to ask our plan to pay you back or to pay

a bill you have received.

1. When you’ve received emergency or urgently needed medical care from a provider who is not in our plan’s network

You can receive emergency services from any provider, whether or not the provider is a part

of our network. When you receive emergency or urgently needed services from a provider

who is not part of our network, you should ask the provider to bill the plan.

• If you pay the entire amount yourself at the time you receive the care, you need to ask

us to pay you back for our share of the cost. Send us the bill, along with documentation

of any payments you have made.

• At times you may get a bill from the provider asking for payment that you think you do

not owe. Send us this bill, along with documentation of any payments you have already

made.

o If the provider is owed anything, we will pay the provider directly.

o If you have already paid more than your share of the cost for the service, we

will determine how much you owed and pay you back for our share of the cost.

2. When a network provider sends you a bill you think you should not pay

Network providers should always bill the plan directly. But sometimes they make mistakes,

and ask you to pay more than your share of the cost.

• You only have to pay your cost-sharing amount when you get services covered by our

plan. We do not allow providers to add additional separate charges, called “balance billing.” This protection (that you never pay more than your cost-sharing amount)

applies even if we pay the provider less than the provider charges for a service and even



if there is a dispute and we don’t pay certain provider charges. For more information

about “balance billing,” go to Chapter 4, Section 1.4.

• Whenever you get a bill from a network provider that you think is more than you

should pay, send us the bill. We will contact the provider directly and resolve the

billing problem.

• If you have already paid a bill to a network provider, but you feel that you paid too

much, send us the bill along with documentation of any payment you have made. You

should ask us to pay you back for the difference between the amount you paid and the

amount you owed under the plan.

3. If you are retroactively enrolled in our plan

Sometimes a person’s enrollment in the plan is retroactive. (Retroactive means that the first

day of their enrollment has already passed. The enrollment date may even have occurred last

year.)

If you were retroactively enrolled in our plan and you paid out-of-pocket for any of your

covered services or drugs after your enrollment date, you can ask us to pay you back for our

share of the costs. You will need to submit paperwork for us to handle the reimbursement.

Please contact Member Services for additional information about how to ask us to pay you

back and deadlines for making your request. (Phone numbers for Member Services are

printed on the back cover of this booklet.)

4. When you use an out-of-network pharmacy to get a prescription filled

If you go to an out-of-network pharmacy and try to use your membership card to fill a

prescription, the pharmacy may not be able to submit the claim directly to us. When that

happens, you will have to pay the full cost of your prescription. (We cover prescriptions

filled at out-of-network pharmacies only in a few special situations. Please go to Chapter 5,

Section 2.5 to learn more.) Save your receipt and send a copy to us when you ask us to pay

you back for our share of the cost.

5. When you pay the full cost for a prescription because you don’t have your plan membership card with you

If you do not have your plan membership card with you, you can ask the pharmacy to call the

plan or to look up your plan enrollment information. However, if the pharmacy cannot get

the enrollment information they need right away, you may need to pay the full cost of the

prescription yourself. Save your receipt and send a copy to us when you ask us to pay you

back for our share of the cost.

6. When you pay the full cost for a prescription in other situations

You may pay the full cost of the prescription because you find that the drug is not covered

for some reason.

• For example, the drug may not be on the plan’s List of Covered Drugs (Formulary); or

it could have a requirement or restriction that you didn’t know about or don’t think

should apply to you. If you decide to get the drug immediately, you may need to pay

the full cost for it.



• Save your receipt and send a copy to us when you ask us to pay you back. In some

situations, we may need to get more information from your doctor in order to pay you

back for our share of the cost of the drug.

When you send us a request for payment, we will review your request and decide whether

the service or drug should be covered. This is called making a “coverage decision.” If we decide it should be covered, we will pay for our share of the cost for the service or drug.

If we deny your request for payment, you can appeal our decision. Chapter 9 of this

booklet (What to do if you have a problem or complaint (coverage decisions, appeals,

complaints)) has information about how to make an appeal.

SECTION 2 How to ask us to pay you back or to pay a bill you have received

Section 2.1 How and where to send us your request for payment

Send us your request for payment, along with your bill and documentation of any payment you

have made. It’s a good idea to make a copy of your bill and receipts for your records.

To make sure you are giving us all the information we need to make a decision, you can fill out

our claim form to make your request for payment.

• You don’t have to use the form, but it will help us process the information faster.

• Either download a copy of the form from our website (www.metroplusmedicare.org) or

call Member Services and ask for the form. (Phone numbers for Member Services are


Mail your request for payment together with any bills or receipts to us at this address:



New York, NY 10038

Attn: Member Services

To request payment for prescription drugs, mail your request for payment together with any bills

or receipts to this address:

CVS Caremark

c/o MetroPlus Health Plan

P.O. Box 52066

Phoenix, Arizona 85072-2066

You may also call our plan to request payment. For details, go to Chapter 2, Section 1 and look

for the section called Where to send a request that asks us to pay for our share of the cost for

medical care or a drug you have received.




You must submit your claim to us within one year of the date you received the service, item,

or drug.

Contact Member Services if you have any questions (phone numbers are printed on the back

cover of this booklet). If you don’t know what you should have paid, or you receive bills and you

don’t know what to do about those bills, we can help. You can also call if you want to give us

more information about a request for payment you have already sent to us.

SECTION 3 We will consider your request for payment and say yes or no

Section 3.1 We check to see whether we should cover the service or drug and how much we owe

When we receive your request for payment, we will let you know if we need any additional

information from you. Otherwise, we will consider your request and make a coverage decision.

• If we decide that the medical care or drug is covered and you followed all the rules for

getting the care or drug, we will pay for our share of the cost for the service. If you have

already paid for the service or drug, we will mail your reimbursement of our share of the

cost to you. If you have not paid for the service or drug yet, we will mail the payment

directly to the provider. (Chapter 3 explains the rules you need to follow for getting your

medical services covered. Chapter 5 explains the rules you need to follow for getting your

Part D prescription drugs covered.)

• If we decide that the medical care or drug is not covered, or you did not follow all the

rules, we will not pay for our share of the cost of the care or drug. Instead, we will send

you a letter that explains the reasons why we are not sending the payment you have

requested and your rights to appeal that decision.

Section 3.2 If we tell you that we will not pay for all or part of the medical care or drug, you can make an appeal

If you think we have made a mistake in turning down your request for payment or you don’t

agree with the amount we are paying, you can make an appeal. If you make an appeal, it means

you are asking us to change the decision we made when we turned down your request for

payment.

For the details on how to make this appeal, go to Chapter 9 of this booklet (What to do if you

have a problem or complaint (coverage decisions, appeals, complaints)). The appeals process is a

formal process with detailed procedures and important deadlines. If making an appeal is new to

you, you will find it helpful to start by reading Section 5 of Chapter 9. Section 5 is an

introductory section that explains the process for coverage decisions and appeals and gives

definitions of terms such as “appeal.” Then after you have read Section 5, you can go to the

section in Chapter 9 that tells what to do for your situation:



• If you want to make an appeal about getting paid back for a medical service, go to

Section 6.3 in Chapter 9.

• If you want to make an appeal about getting paid back for a drug, go to Section 7.5 of

Chapter 9.

SECTION 4 Other situations in which you should save your receipts and send copies to us

Section 4.1 In some cases, you should send copies of your receipts to us to help us track your out-of-pocket drug costs

There are some situations when you should let us know about payments you have made for your

drugs. In these cases, you are not asking us for payment. Instead, you are telling us about your

payments so that we can calculate your out-of-pocket costs correctly. This may help you to

qualify for the Catastrophic Coverage Stage more quickly.

Below is an example of a situation when you should send us copies of receipts to let us know

about payments you have made for your drugs:

When you get a drug through a patient assistance program offered by a drug manufacturer

Some members are enrolled in a patient assistance program offered by a drug manufacturer

that is outside the plan benefits. If you get any drugs through a program offered by a drug

manufacturer, you may pay a copayment to the patient assistance program.

• Save your receipt and send a copy to us so that we can have your out-of-pocket

expenses count toward qualifying you for the Catastrophic Coverage Stage.

• Please note: Because you are getting your drug through the patient assistance program

and not through the plan’s benefits, we will not pay for any share of these drug costs.

But sending a copy of the receipt allows us to calculate your out-of-pocket costs

correctly and may help you qualify for the Catastrophic Coverage Stage more quickly.

Since you are not asking for payment in the case described above, this situation is not considered

a coverage decision. Therefore, you cannot make an appeal if you disagree with our decision.

CHAPTER 8

Your rights and responsibilities


Chapter 8. Your rights and responsibilities


SECTION 1 Our plan must honor your rights as a member of the plan ........ 151

Section 1.1 We must provide information in a way that works for you (in languages

other than English, in Braille, in large print, or other alternate formats,

etc.) .............................................................................................................. 151

Sección 1.1 Nosotros debemos proporcionarle información de una manera que le sea

práctica (en idiomas distintos del inglés, en Braille, en letra grande o en

otros formatos alternativos, etc.). ................................................................ 151

第1.1節我們必須向您提供適宜於您的資訊（英文之外的語言版本、盲文、

大號印刷體或其他格式等） ..................................................................... 152

Section 1.2 We must treat you with fairness and respect at all times ............................ 152

Section 1.3 We must ensure that you get timely access to your covered services and

drugs ............................................................................................................ 152

Section 1.4 We must protect the privacy of your personal health information.............. 153

Section 1.5 We must give you information about the plan, its network of providers,

and your covered services ........................................................................... 154

Section 1.6 We must support your right to make decisions about your care ................. 155

Section 1.7 You have the right to make complaints and to ask us to reconsider

decisions we have made .............................................................................. 157

Section 1.8 What can you do if you believe you are being treated unfairly or your

rights are not being respected? .................................................................... 157

Section 1.9 How to get more information about your rights.......................................... 158

SECTION 2 You have some responsibilities as a member of the plan .......... 158

Section 2.1 What are your responsibilities? ................................................................... 158



SECTION 1 Our plan must honor your rights as a member of the plan

Section 1.1 We must provide information in a way that works for you (in languages other than English, in Braille, in large print, or other alternate formats, etc.)

To get information from us in a way that works for you, please call Member Services (phone


Our plan has people and free interpreter services available to answer questions from disabled and

non-English speaking members. Our significant materials are available in languages other than

English upon request. We can also give you information in Braille, in large print, or other

alternate formats at no cost if you need it. We are required to give you information about the

plan’s benefits in a format that is accessible and appropriate for you. To get information from us

in a way that works for you, please call Member Services (phone numbers are printed on the

back cover of this booklet) or contact Sony Tapia at 212-908-8600.

If you have any trouble getting information from our plan in a format that is accessible and

appropriate for you, please call to file a grievance with the plan (phone numbers are printed on

the back of this booklet). You may also file a complaint with Medicare by calling 1-800-

MEDICARE (1-800-633-4227) or directly with the Office for Civil Rights. Contact information

is included in this Evidence of Coverage or with this mailing, or you may contact Member

Services for additional information.

Sección 1.1 Nosotros debemos proporcionarle información de una manera que le sea práctica (en idiomas distintos del inglés, en Braille, en letra grande o en otros formatos alternativos, etc.).

Por favor, comuníquese con Servicios al Miembro para obtener información de una manera que

le sea práctica (los números de teléfono están impresos en la contratapa de este folleto).

Nuestro plan cuenta con personas y servicios de intérprete gratuitos para responder las

preguntas de los miembros incapacitados y que no hablan inglés. Nuestros materiales escritos

importantes se encuentran disponibles en otros idiomas aparte del inglés a pedido. También

podemos darle la información en Braille, letra grande o en otros formatos alternativos sin costo

alguno si lo necesita. Estamos obligados a darle información sobre los beneficios del plan en

un formato que sea accesible y adecuado para usted. Por favor, comuníquese con Servicios al

Miembro para obtener información que le sea práctica (los números de teléfono están impresos

en la contratapa de este folleto) o comuníquese con Sony Tapia al 212-908-8600.

Si tiene problemas para obtener información de nuestro plan en un formato que sea accesible y

adecuado para usted, llame para presentar una queja ante el plan (los números de teléfono están

impresos al dorso de este folleto). También puede presentar una queja ante Medicare llamando al

1-800-MEDICARE (1-800-633-4227) o directamente a la Oficina de Derechos Civiles. La



información de contacto se incluye en esta Evidencia de Cobertura o con este envío por correo, o

puede comunicarse con Servicios para Miembros para obtener información adicional.

第1.1節我們必須向您提供適宜於您的資訊（英文之外的語言版本、盲文、大號印刷體或其他格式等）

要從我處取得適宜於您的資訊，請致電會員服務部（電話號碼已印於本手冊的封底）。

本計劃可提供人員以及免費的語言翻譯服務，能夠回答殘障和母語並非英語的會員提出

的問題。一些重要材料可提供非英語版本。我們還能夠以盲文、大號字型印刷體或您需

要的其他可選形式免費向您提供資訊。我們需採用您可獲得及適合您的形式向您提供計

劃福利的相關資訊。要從我處獲得適宜於您的資訊，請致電會員服務部（電話號碼已印

於本手冊的封底）或聯絡Sony Tapia，電話為212-908-8600。

如果您在以便於您使用且適宜您的格式獲得計劃資訊方面遇到任何困難，請致電並向該計

劃提出申訴（電話號碼印在本手冊背面）。您還可以透過致電1-800-MEDICARE（1-800-

633-4227）向Medicare或直接向民權辦公室提出投訴。此承保範圍說明書或此郵件中包含

了聯絡資訊，或者您可以聯絡會員服務部，瞭解其他資訊。

Section 1.2 We must treat you with fairness and respect at all times

Our plan must obey laws that protect you from discrimination or unfair treatment. We do not

discriminate based on a person’s race, ethnicity, national origin, religion, gender, age, mental or

physical disability, health status, claims experience, medical history, genetic information,

evidence of insurability, or geographic location within the service area.

If you want more information or have concerns about discrimination or unfair treatment, please

call the Department of Health and Human Services’ Office for Civil Rights at 1-800-368-1019

(TTY 1-800-537-7697) or your local Office for Civil Rights.

If you have a disability and need help with access to care, please call us at Member Services

(phone numbers are printed on the back cover of this booklet). If you have a complaint, such as a

problem with wheelchair access, Member Services can help.

Section 1.3 We must ensure that you get timely access to your covered services and drugs

As a member of our plan, you have the right to choose a primary care provider (PCP) in the

plan’s network to provide and arrange for your covered services (Chapter 3 explains more about

this). Call Member Services to learn which doctors are accepting new patients (phone numbers

are printed on the back cover of this booklet). You also have the right to go to a women’s health

specialist (such as a gynecologist) without a referral.



As a plan member, you have the right to get appointments and covered services from the plan’s

network of providers within a reasonable amount of time. This includes the right to get timely

services from specialists when you need that care. You also have the right to get your

prescriptions filled or refilled at any of our network pharmacies without long delays.

If you think that you are not getting your medical care or Part D drugs within a reasonable

amount of time, Chapter 9, Section 11 of this booklet tells what you can do. (If we have denied

coverage for your medical care or drugs and you don’t agree with our decision, Chapter 9,

Section 5 tells what you can do.)

Section 1.4 We must protect the privacy of your personal health information

Federal and state laws protect the privacy of your medical records and personal health

information. We protect your personal health information as required by these laws.

• Your “personal health information” includes the personal information you gave us when

you enrolled in this plan as well as your medical records and other medical and health

information.

• The laws that protect your privacy give you rights related to getting information and

controlling how your health information is used. We give you a written notice, called a

“Notice of Privacy Practice,” that tells about these rights and explains how we protect the

privacy of your health information.

How do we protect the privacy of your health information?

• We make sure that unauthorized people don’t see or change your records.

• In most situations, if we give your health information to anyone who isn’t providing your

care or paying for your care, we are required to get written permission from you first.

Written permission can be given by you or by someone you have given legal power to

make decisions for you.

• There are certain exceptions that do not require us to get your written permission first.

These exceptions are allowed or required by law.

o For example, we are required to release health information to government

agencies that are checking on quality of care.

o Because you are a member of our plan through Medicare, we are required to give

Medicare your health information including information about your Part D

prescription drugs. If Medicare releases your information for research or other

uses, this will be done according to Federal statutes and regulations.

You can see the information in your records and know how it has been shared with others

You have the right to look at your medical records held at the plan, and to get a copy of your

records. We are allowed to charge you a fee for making copies. You also have the right to ask us



to make additions or corrections to your medical records. If you ask us to do this, we will work

with your health care provider to decide whether the changes should be made.

You have the right to know how your health information has been shared with others for any

purposes that are not routine.

If you have questions or concerns about the privacy of your personal health information, please


Section 1.5 We must give you information about the plan, its network of providers, and your covered services

As a member of MetroPlus Advantage Plan (HMO SNP), you have the right to get several kinds

of information from us. (As explained above in Section 1.1, you have the right to get information

from us in a way that works for you. This includes getting the information in languages other

than English and in large print or other alternate formats.)

If you want any of the following kinds of information, please call Member Services (phone

numbers are printed on the back cover of this booklet):

• Information about our plan. This includes, for example, information about the plan’s

financial condition. It also includes information about the number of appeals made by

members and the plan’s performance ratings, including how it has been rated by plan

members and how it compares to other Medicare health plans.

• Information about our network providers including our network pharmacies.

o For example, you have the right to get information from us about the

qualifications of the providers and pharmacies in our network and how we pay the

providers in our network.

o For a list of the providers and pharmacies in the plan’s network, see the

Provider/Pharmacy Directory.

o For more detailed information about our providers or pharmacies, you can call

Member Services (phone numbers are printed on the back cover of this booklet)

or visit our website at www.metroplusmedicare.org.

• Information about your coverage and the rules you must follow when using your

coverage.

o In Chapters 3 and 4 of this booklet, we explain what medical services are covered

for you, any restrictions to your coverage, and what rules you must follow to get

your covered medical services.

o To get the details on your Part D prescription drug coverage, see Chapters 5 and 6

of this booklet plus the plan’s List of Covered Drugs (Formulary). These chapters,

together with the List of Covered Drugs (Formulary), tell you what drugs are

covered and explain the rules you must follow and the restrictions to your

coverage for certain drugs.




o If you have questions about the rules or restrictions, please call Member Services

(phone numbers are printed on the back cover of this booklet).

• Information about why something is not covered and what you can do about it.

o If a medical service or Part D drug is not covered for you, or if your coverage is

restricted in some way, you can ask us for a written explanation. You have the

right to this explanation even if you received the medical service or drug from an

out-of-network provider or pharmacy.

o If you are not happy or if you disagree with a decision we make about what

medical care or Part D drug is covered for you, you have the right to ask us to

change the decision. You can ask us to change the decision by making an appeal.

For details on what to do if something is not covered for you in the way you think

it should be covered, see Chapter 9 of this booklet. It gives you the details about

how to make an appeal if you want us to change our decision. (Chapter 9 also tells

about how to make a complaint about quality of care, waiting times, and other

concerns.)

o If you want to ask our plan to pay our share of a bill you have received for

medical care or a Part D prescription drug, see Chapter 7 of this booklet.

Section 1.6 We must support your right to make decisions about your care

You have the right to know your treatment options and participate in decisions about your health care

You have the right to get full information from your doctors and other health care providers

when you go for medical care. Your providers must explain your medical condition and your

treatment choices in a way that you can understand.

You also have the right to participate fully in decisions about your health care. To help you make

decisions with your doctors about what treatment is best for you, your rights include the

following:

• To know about all of your choices. This means that you have the right to be told about

all of the treatment options that are recommended for your condition, no matter what they

cost or whether they are covered by our plan. It also includes being told about programs

our plan offers to help members manage their medications and use drugs safely.

• To know about the risks. You have the right to be told about any risks involved in your

care. You must be told in advance if any proposed medical care or treatment is part of a

research experiment. You always have the choice to refuse any experimental treatments.

• The right to say “no.” You have the right to refuse any recommended treatment. This

includes the right to leave a hospital or other medical facility, even if your doctor advises

you not to leave. You also have the right to stop taking your medication. Of course, if you

refuse treatment or stop taking medication, you accept full responsibility for what

happens to your body as a result.



• To receive an explanation if you are denied coverage for care. You have the right to

receive an explanation from us if a provider has denied care that you believe you should

receive. To receive this explanation, you will need to ask us for a coverage decision.

Chapter 9 of this booklet tells how to ask the plan for a coverage decision.

You have the right to give instructions about what is to be done if you are not able to make medical decisions for yourself

Sometimes people become unable to make health care decisions for themselves due to accidents

or serious illness. You have the right to say what you want to happen if you are in this situation.

This means that, if you want to, you can:

• Fill out a written form to give someone the legal authority to make medical decisions

for you if you ever become unable to make decisions for yourself.

• Give your doctors written instructions about how you want them to handle your

medical care if you become unable to make decisions for yourself.

The legal documents that you can use to give your directions in advance in these situations are

called “advance directives.” There are different types of advance directives and different names

for them. Documents called “living will” and “power of attorney for health care” are examples

of advance directives.

If you want to use an “advance directive” to give your instructions, here is what to do:

• Get the form. If you want to have an advance directive, you can get a form from your

lawyer, from a social worker, or from some office supply stores. You can sometimes get

advance directive forms from organizations that give people information about Medicare.

You can also contact Member Services to ask for the forms (phone numbers are printed

on the back cover of this booklet).

• Fill it out and sign it. Regardless of where you get this form, keep in mind that it is a

legal document. You should consider having a lawyer help you prepare it.

• Give copies to appropriate people. You should give a copy of the form to your doctor

and to the person you name on the form as the one to make decisions for you if you can’t.

You may want to give copies to close friends or family members as well. Be sure to keep

a copy at home.

New York State has its own Health Care Proxy Form. For more information, you can contact

311 or call the NYS Department of Health at 1-800-628-5971

If you know ahead of time that you are going to be hospitalized, and you have signed an advance

directive, take a copy with you to the hospital.

• If you are admitted to the hospital, they will ask you whether you have signed an advance

directive form and whether you have it with you.



• If you have not signed an advance directive form, the hospital has forms available and

will ask if you want to sign one.

Remember, it is your choice whether you want to fill out an advance directive (including

whether you want to sign one if you are in the hospital). According to law, no one can deny you

care or discriminate against you based on whether or not you have signed an advance directive.

What if your instructions are not followed?

If you have signed an advance directive, and you believe that a doctor or hospital did not follow

the instructions in it, you may file a complaint with the New York State Department of Health by

calling 1-800-206-8125, or in writing to NYSDOH, Bureau of Certification and Surveillance,

Corning Tower, Albany, NY 12237.

Section 1.7 You have the right to make complaints and to ask us to reconsider decisions we have made

If you have any problems or concerns about your covered services or care, Chapter 9 of this

booklet tells what you can do. It gives the details about how to deal with all types of problems

and complaints. What you need to do to follow up on a problem or concern depends on the

situation. You might need to ask our plan to make a coverage decision for you, make an appeal

to us to change a coverage decision, or make a complaint. Whatever you do – ask for a coverage

decision, make an appeal, or make a complaint – we are required to treat you fairly.

You have the right to get a summary of information about the appeals and complaints that other

members have filed against our plan in the past. To get this information, please call Member


Section 1.8 What can you do if you believe you are being treated unfairly or your rights are not being respected?

If it is about discrimination, call the Office for Civil Rights

If you believe you have been treated unfairly or your rights have not been respected due to your

race, disability, religion, sex, health, ethnicity, creed (beliefs), age, or national origin, you should

call the Department of Health and Human Services’ Office for Civil Rights at 1-800-368-1019

or TTY 1-800-537-7697, or call your local Office for Civil Rights.

Is it about something else?

If you believe you have been treated unfairly or your rights have not been respected, and it’s not

about discrimination, you can get help dealing with the problem you are having:

• You can call Member Services (phone numbers are printed on the back cover of this

booklet).



• You can call the State Health Insurance Assistance Program. For details about this

organization and how to contact it, go to Chapter 2, Section 3.

• Or, you can call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7

days a week. TTY users should call 1-877-486-2048.

Section 1.9 How to get more information about your rights

There are several places where you can get more information about your rights:


booklet).

• You can call the State Health Insurance Assistance Program. For details about this

organization and how to contact it, go to Chapter 2, Section 3.

• You can contact Medicare.

o You can visit the Medicare website to read or download the publication “Your

Medicare Rights & Protections.” (The publication is available at:

https://www.medicare.gov/Pubs/pdf/11534.pdf.)

o Or, you can call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a

week. TTY users should call 1-877-486-2048.

SECTION 2 You have some responsibilities as a member of the plan

Section 2.1 What are your responsibilities?

Things you need to do as a member of the plan are listed below. If you have any questions,

please call Member Services (phone numbers are printed on the back cover of this booklet).

We’re here to help.

• Get familiar with your covered services and the rules you must follow to get these

covered services. Use this Evidence of Coverage booklet to learn what is covered for

you and the rules you need to follow to get your covered services.

o Chapters 3 and 4 give the details about your medical services, including what is

covered, what is not covered, rules to follow, and what you pay.

o Chapters 5 and 6 give the details about your coverage for Part D prescription

drugs.

• If you have any other health insurance coverage or prescription drug coverage in

addition to our plan, you are required to tell us. Please call Member Services to let us

know (phone numbers are printed on the back cover of this booklet).

o We are required to follow rules set by Medicare and Medicaid to make sure that

you are using all of your coverage in combination when you get your covered




services from our plan. This is called “coordination of benefits” because it involves coordinating the health and drug benefits you get from our plan with any

other health and drug benefits available to you. We’ll help you coordinate your

benefits. (For more information about coordination of benefits, go to Chapter 1,

Section 7.)

• Tell your doctor and other health care providers that you are enrolled in our plan.

Show your plan membership card and your Medicaid card whenever you get your

medical care or Part D prescription drugs.

• Help your doctors and other providers help you by giving them information, asking

questions, and following through on your care.

o To help your doctors and other health providers give you the best care, learn as

much as you are able to about your health problems and give them the

information they need about you and your health. Follow the treatment plans and

instructions that you and your doctors agree upon.

o Make sure your doctors know all of the drugs you are taking, including over-the-

counter drugs, vitamins, and supplements.

o If you have any questions, be sure to ask. Your doctors and other health care

providers are supposed to explain things in a way you can understand. If you ask a

question and you don’t understand the answer you are given, ask again.

• Be considerate. We expect all our members to respect the rights of other patients. We

also expect you to act in a way that helps the smooth running of your doctor’s office,

hospitals, and other offices.

• Pay what you owe. As a plan member, you are responsible for these payments:

o You must pay your plan premiums to continue being a member of our plan.

o In order to be eligible for our plan, you must have Medicare Part A and Medicare

Part B. For most MetroPlus Advantage Plan (HMO SNP) members, Medicaid

pays for your Part A premium (if you don’t qualify for it automatically) and for

your Part B premium. If Medicaid is not paying your Medicare premiums for you,

you must continue to pay your Medicare premiums to remain a member of the

plan.

o For most of your medical services or drugs covered by the plan, you must pay

your share of the cost when you get the service or drug. This will be a copayment

(a fixed amount) or coinsurance (a percentage of the total cost). Chapter 4 tells

what you must pay for your medical services. Chapter 6 tells what you must pay

for your Part D prescription drugs.

o If you get any medical services or drugs that are not covered by our plan or by

other insurance you may have, you must pay the full cost.

▪ If you disagree with our decision to deny coverage for a service or drug,

you can make an appeal. Please see Chapter 9 of this booklet for

information about how to make an appeal.

o If you are required to pay a late enrollment penalty, you must pay the penalty to

keep your prescription drug coverage.



o If you are required to pay the extra amount for Part D because of your higher

income (as reported on your last tax return), you must pay the extra amount

directly to the government to remain a member of the plan.

• Tell us if you move. If you are going to move, it’s important to tell us right away. Call Member Services (phone numbers are printed on the back cover of this booklet).

o If you move outside of our plan service area, you cannot remain a member of

our plan. (Chapter 1 tells about our service area.) We can help you figure out

whether you are moving outside our service area. If you are leaving our service

area, you will have a Special Enrollment Period when you can join any Medicare

plan available in your new area.

o If you move within our service area, we still need to know so we can keep your

membership record up to date and know how to contact you.

o If you move, it is also important to tell Social Security (or the Railroad

Retirement Board). You can find phone numbers and contact information for

these organizations in Chapter 2.

• Call Member Services for help if you have questions or concerns. We also welcome

any suggestions you may have for improving our plan.

o Phone numbers and calling hours for Member Services are printed on the back

cover of this booklet.

o For more information on how to reach us, including our mailing address, please

see Chapter 2.

CHAPTER 9

What to do if you have a problem or complaint (coverage decisions,

appeals, complaints)


Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)


BACKGROUND ......................................................................................................... 165


Section 1.1 What to do if you have a problem or concern ............................................. 165

Section 1.2 What about the legal terms? ........................................................................ 165

SECTION 2 You can get help from government organizations that are not connected with us.................................................................... 166

Section 2.1 Where to get more information and personalized assistance ...................... 166

SECTION 3 To deal with your problem, which process should you use?..... 167

Section 3.1 Should you use the process for Medicare benefits or Medicaid benefits? .. 167

PROBLEMS ABOUT YOUR MEDICARE BENEFITS ................................................ 168

SECTION 4 Handling problems about your Medicare benefits ...................... 168

Section 4.1 Should you use the process for coverage decisions and appeals? Or

should you use the process for making complaints? ................................... 168

SECTION 5 A guide to the basics of coverage decisions and appeals ......... 168

Section 5.1 Asking for coverage decisions and making appeals: the big picture .......... 168

Section 5.2 How to get help when you are asking for a coverage decision or making

an appeal...................................................................................................... 169

Section 5.3 Which section of this chapter gives the details for your situation?............. 170

SECTION 6 Your medical care: How to ask for a coverage decision or make an appeal............................................................................... 171

Section 6.1 This section tells what to do if you have problems getting coverage for

medical care or if you want us to pay you back for our share of the cost of

your care ...................................................................................................... 171

Section 6.2 Step-by-step: How to ask for a coverage decision (how to ask our plan to

authorize or provide the medical care coverage you want)......................... 172

Section 6.3 Step-by-step: How to make a Level 1 Appeal (How to ask for a review of

a medical care coverage decision made by our plan) .................................. 175

Section 6.4 Step-by-step: How a Level 2 Appeal is done .............................................. 178

Section 6.5 What if you are asking us to pay you back for our share of a bill you have

received for medical care?........................................................................... 180



SECTION 7 Your Part D prescription drugs: How to ask for a coverage decision or make an appeal........................................................... 181

Section 7.1 This section tells you what to do if you have problems getting a Part D

drug or you want us to pay you back for a Part D drug .............................. 181

Section 7.2 What is an exception?.................................................................................. 183

Section 7.3 Important things to know about asking for exceptions ............................... 184

Section 7.4 Step-by-step: How to ask for a coverage decision, including an exception 185

Section 7.5 Step-by-step: How to make a Level 1 Appeal (how to ask for a review of

a coverage decision made by our plan) ....................................................... 188

Section 7.6 Step-by-step: How to make a Level 2 Appeal............................................. 190

SECTION 8 How to ask us to cover a longer inpatient hospital stay if you think the doctor is discharging you too soon ...................... 192

Section 8.1 During your inpatient hospital stay, you will get a written notice from

Medicare that tells about your rights ........................................................... 193

Section 8.2 Step-by-step: How to make a Level 1 Appeal to change your hospital

discharge date .............................................................................................. 194

Section 8.3 Step-by-step: How to make a Level 2 Appeal to change your hospital

discharge date .............................................................................................. 197

Section 8.4 What if you miss the deadline for making your Level 1 Appeal?............... 198

SECTION 9 How to ask us to keep covering certain medical services if you think your coverage is ending too soon ............................... 201

Section 9.1 This section is about three services only: Home health care, skilled

nursing facility care, and Comprehensive Outpatient Rehabilitation

Facility (CORF) services............................................................................. 201

Section 9.2 We will tell you in advance when your coverage will be ending................ 202

Section 9.3 Step-by-step: How to make a Level 1 Appeal to have our plan cover your

care for a longer time................................................................................... 202

Section 9.4 Step-by-step: How to make a Level 2 Appeal to have our plan cover your

care for a longer time................................................................................... 204

Section 9.5 What if you miss the deadline for making your Level 1 Appeal?............... 206

SECTION 10 Taking your appeal to Level 3 and beyond .................................. 208

Section 10.1 Levels of Appeal 3, 4, and 5 for Medical Service Appeals......................... 208

Section 10.2 Levels of Appeal 3, 4, and 5 for Part D Drug Appeals ............................... 210

SECTION 11 How to make a complaint about quality of care, waiting times, customer service, or other concerns ................................ 211

Section 11.1 What kinds of problems are handled by the complaint process? ................ 211

Section 11.2 The formal name for “making a complaint” is “filing a grievance” ........... 213

Section 11.3 Step-by-step: Making a complaint .............................................................. 213



Section 11.4 You can also make complaints about quality of care to the Quality

Improvement Organization.......................................................................... 214

Section 11.5 You can also tell Medicare about your complaint....................................... 214

PROBLEMS ABOUT YOUR MEDICAID BENEFITS.................................................. 215

SECTION 12 Handling problems about your Medicaid benefits....................... 215



BACKGROUND


Section 1.1 What to do if you have a problem or concern

This chapter explains the processes for handling problems and concerns. The process you use to

handle your problem depends on two things:

1. Whether your problem is about benefits covered by Medicare or Medicaid. If you would

like help deciding whether to use the Medicare process or the Medicaid process, or both,

please contact Member Services (phone numbers are printed on the back cover of this

booklet).

2. The type of problem you are having:

o For some types of problems, you need to use the process for coverage decisions

and appeals.

o For other types of problems, you need to use the process for making complaints.

These processes have been approved by Medicare. To ensure fairness and prompt handling of

your problems, each process has a set of rules, procedures, and deadlines that must be followed

by us and by you.

Which one do you use? The guide in Section 3 will help you identify the right process to use.

Section 1.2 What about the legal terms?

There are technical legal terms for some of the rules, procedures, and types of deadlines

explained in this chapter. Many of these terms are unfamiliar to most people and can be hard to

understand.

To keep things simple, this chapter explains the legal rules and procedures using simpler words

in place of certain legal terms. For example, this chapter generally says “making a complaint” rather than “filing a grievance,” “coverage decision” rather than “organization determination” or “coverage determination” or “at-risk determination,” and “Independent Review Organization” instead of “Independent Review Entity.” It also uses abbreviations as little as possible.

However, it can be helpful – and sometimes quite important – for you to know the correct legal

terms for the situation you are in. Knowing which terms to use will help you communicate more

clearly and accurately when you are dealing with your problem and get the right help or

information for your situation. To help you know which terms to use, we include legal terms

when we give the details for handling specific types of situations.



SECTION 2 You can get help from government organizations that are not connected with us

Section 2.1 Where to get more information and personalized assistance

Sometimes it can be confusing to start or follow through the process for dealing with a problem.

This can be especially true if you do not feel well or have limited energy. Other times, you may

not have the knowledge you need to take the next step.

Get help from an independent government organization

We are always available to help you. But in some situations you may also want help or guidance

from someone who is not connected with us. You can always contact your State Health

Insurance Assistance Program (SHIP). This government program has trained counselors in

every state. The program is not connected with us or with any insurance company or health plan.

The counselors at this program can help you understand which process you should use to handle

a problem you are having. They can also answer your questions, give you more information, and

offer guidance on what to do.

The services of SHIP counselors are free. You will find phone numbers in Chapter 2, Section 3

of this booklet.

You can also get help and information from Medicare

For more information and help in handling a problem, you can also contact Medicare. Here are

two ways to get information directly from Medicare:

• You can call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week.

TTY users should call 1-877-486-2048.

• You can visit the Medicare website (https://www.medicare.gov).

You can get help and information from Medicaid

For more information and help in handling a problem, you can also contact Medicaid.

• You can contact the New York Medicaid CHOICE Hotline at 1-800-505-5678.

• You can contact the New York Department of Health by calling 311.




SECTION 3 To deal with your problem, which process should you use?

Section 3.1 Should you use the process for Medicare benefits or Medicaid benefits?

Because you have Medicare and get assistance from Medicaid, you have different processes that

you can use to handle your problem or complaint. Which process you use depends on whether

the problem is about Medicare benefits or Medicaid benefits. If your problem is about a benefit

covered by Medicare, then you should use the Medicare process. If your problem is about a

benefit covered by Medicaid, then you should use the Medicaid process. If you would like help

deciding whether to use the Medicare process or the Medicaid process, please contact Member


The Medicare process and Medicaid process are described in different parts of this chapter. To

find out which part you should read, use the chart below.

To figure out which part of this chapter will help with your specific problem or concern,

START HERE

Is your problem about Medicare benefits or Medicaid benefits?

(If you would like help deciding whether your problem is about Medicare benefits or

Medicaid benefits, please contact Member Services. Phone numbers for Member Services are


My problem is about Medicare benefits.

Go to the next section of this chapter, Section 4, “Handling problems about

Medicare your benefits.”

My problem is about Medicaid coverage.

Skip ahead to Section 12 of this chapter, “Handling problems about your

Medicaid benefits.”



PROBLEMS ABOUT YOUR MEDICARE BENEFITS

SECTION 4 Handling problems about your Medicare benefits

Section 4.1 Should you use the process for coverage decisions and appeals? Or should you use the process for making complaints?

If you have a problem or concern, you only need to read the parts of this chapter that apply to

your situation. The chart below will help you find the right section of this chapter for problems

or complaints about benefits covered by Medicare.

To figure out which part of this chapter will help with your problem or concern about your

Medicare benefits, use this chart:

Is your problem or concern about your benefits or coverage?

(This includes problems about whether particular medical care or prescription drugs are

covered or not, the way in which they are covered, and problems related to payment for

medical care or prescription drugs.)

Yes. My problem is about benefits or coverage.

Go on to the next section of this chapter, Section 5, “A guide to the basics of coverage decisions and appeals.”

No. My problem is not about benefits or coverage.

Skip ahead to Section 11 at the end of this chapter: “How to make a complaint

about quality of care, waiting times, customer service or other concerns.”

SECTION 5 A guide to the basics of coverage decisions and appeals

Section 5.1 Asking for coverage decisions and making appeals: the big picture

The process for asking for coverage decisions and appeals deals with problems related to your

benefits and coverage, including problems related to payment. This is the process you use for

issues such as whether something is covered or not and the way in which something is covered.



Asking for coverage decisions

A coverage decision is a decision we make about your benefits and coverage or about the amount

we will pay for your medical services or drugs. We are making a coverage decision whenever we

decide what is covered for you and how much we pay. For example, your plan network doctor

makes a (favorable) coverage decision for you whenever you receive medical care from him or

her or if your network doctor refers you to a medical specialist. You or your doctor can also

contact us and ask for a coverage decision if your doctor is unsure whether we will cover a

particular medical service or refuses to provide medical care you think that you need. In other

words, if you want to know if we will cover a medical service before you receive it, you can ask

us to make a coverage decision for you.

In some cases, we might decide a service or drug is not covered or is no longer covered by

Medicare for you. If you disagree with this coverage decision, you can make an appeal.

Making an appeal

If we make a coverage decision and you are not satisfied with this decision, you can “appeal” the

decision. An appeal is a formal way of asking us to review and change a coverage decision we

have made.

When you appeal a decision for the first time, this is called a Level 1 Appeal. In this appeal, we

review the coverage decision we made to check to see if we were following all of the rules

properly. Your appeal is handled by different reviewers than those who made the original

unfavorable decision. When we have completed the review we give you our decision. Under

certain circumstances, which we discuss later, you can request an expedited or “fast coverage decision” or fast appeal of a coverage decision.

If we say no to all or part of your Level 1 Appeal, you can go on to a Level 2 Appeal. The Level

2 Appeal is conducted by an independent organization that is not connected to us. (In some

situations, your case will be automatically sent to the independent organization for a Level 2

Appeal. If this happens, we will let you know. In other situations, you will need to ask for a

Level 2 Appeal.) If you are not satisfied with the decision at the Level 2 Appeal, you may be

able to continue through additional levels of appeal.

Section 5.2 How to get help when you are asking for a coverage decision or making an appeal

Would you like some help? Here are resources you may wish to use if you decide to ask for any

kind of coverage decision or appeal a decision:

• You can call us at Member Services (phone numbers are printed on the back cover of

this booklet).

• To get free help from an independent organization that is not connected with our plan,

contact your State Health Insurance Assistance Program (see Section 2 of this chapter).

• Your doctor can make a request for you.



o For medical care, your doctor can request a coverage decision or a Level 1 Appeal

on your behalf. If your appeal is denied at Level 1, it will be automatically

forwarded to Level 2. To request any appeal after Level 2, your doctor must be

appointed as your representative.

o For Part D prescription drugs, your doctor or other prescriber can request a

coverage decision or a Level 1 or Level 2 Appeal on your behalf. To request any

appeal after Level 2, your doctor or other prescriber must be appointed as your

representative.

• You can ask someone to act on your behalf. If you want to, you can name another

person to act for you as your “representative” to ask for a coverage decision or make an

appeal.

o There may be someone who is already legally authorized to act as your

representative under State law.

o If you want a friend, relative, your doctor or other provider, or other person to be

your representative, call Member Services (phone numbers are printed on the

back cover of this booklet) and ask for the “Appointment of Representative” form. (The form is also available on Medicare’s website at

https://www.cms.hhs.gov/cmsforms/downloads/cms1696.pdf or on our website at

www.metroplusmedicare.org.) The form gives that person permission to act on

your behalf. It must be signed by you and by the person who you would like to act

on your behalf. You must give us a copy of the signed form.

• You also have the right to hire a lawyer to act for you. You may contact your own

lawyer, or get the name of a lawyer from your local bar association or other referral

service. There are also groups that will give you free legal services if you qualify.

However, you are not required to hire a lawyer to ask for any kind of coverage

decision or appeal a decision.

Section 5.3 Which section of this chapter gives the details for your situation?

There are four different types of situations that involve coverage decisions and appeals. Since

each situation has different rules and deadlines, we give the details for each one in a separate

section:

• Section 6 of this chapter: “Your medical care: How to ask for a coverage decision or make an appeal”

• Section 7 of this chapter: “Your Part D prescription drugs: How to ask for a coverage decision or make an appeal”

• Section 8 of this chapter: “How to ask us to cover a longer inpatient hospital stay if you

think the doctor is discharging you too soon”

• Section 9 of this chapter: “How to ask us to keep covering certain medical services if you

think your coverage is ending too soon” (Applies to these services only: home health

https://www.cms.hhs.gov/cmsforms/downloads/cms1696.pdf




care, skilled nursing facility care, and Comprehensive Outpatient Rehabilitation Facility

(CORF) services)

If you’re not sure which section you should be using, please call Member Services (phone

numbers are printed on the back cover of this booklet). You can also get help or information

from government organizations such as your State Health Insurance Assistance Program

(Chapter 2, Section 3, of this booklet has the phone numbers for this program).

SECTION 6 Your medical care: How to ask for a coverage decision or make an appeal

Have you read Section 5 of this chapter (A guide to “the basics” of

coverage decisions and appeals)? If not, you may want to read it before you start this section.

Section 6.1 This section tells what to do if you have problems getting coverage for medical care or if you want us to pay you back for our share of the cost of your care

This section is about your benefits for medical care and services. These benefits are described in

Chapter 4 of this booklet: Benefits Chart (what is covered and what you pay). To keep things

simple, we generally refer to “medical care coverage” or “medical care” in the rest of this

section, instead of repeating “medical care or treatment or services” every time.

This section tells what you can do if you are in any of the five following situations:

1. You are not getting certain medical care you want, and you believe that this care is

covered by our plan.

2. Our plan will not approve the medical care your doctor or other medical provider wants

to give you, and you believe that this care is covered by the plan.

3. You have received medical care or services that you believe should be covered by the

plan, but we have said we will not pay for this care.

4. You have received and paid for medical care or services that you believe should be

covered by the plan, and you want to ask our plan to reimburse you for this care.

5. You are being told that coverage for certain medical care you have been getting that we

previously approved will be reduced or stopped, and you believe that reducing or

stopping this care could harm your health.

• NOTE: If the coverage that will be stopped is for hospital care, home health care,

skilled nursing facility care, or Comprehensive Outpatient Rehabilitation

Facility (CORF) services, you need to read a separate section of this chapter because

special rules apply to these types of care. Here’s what to read in those situations:

o Chapter 9, Section 8: How to ask us to cover a longer inpatient hospital stay if

you think the doctor is discharging you too soon.



o Chapter 9, Section 9: How to ask us to keep covering certain medical services if

you think your coverage is ending too soon. This section is about three services

only: home health care, skilled nursing facility care, and Comprehensive

Outpatient Rehabilitation Facility (CORF) services.

• For all other situations that involve being told that medical care you have been getting

will be stopped, use this section (Section 6) as your guide for what to do.

Which of these situations are you in?

If you are in this situation: This is what you can do:

Do you want to find out whether we will

cover the medical care or services you

want?

You can ask us to make a coverage decision for

you.

Go to the next section of this chapter, Section 6.2.

Have we already told you that we will not

cover or pay for a medical service in the

way that you want it to be covered or

paid for?

You can make an appeal. (This means you are

asking us to reconsider.)

Skip ahead to Section 6.3 of this chapter.

Do you want to ask us to pay you back

for medical care or services you have

already received and paid for?

You can send us the bill.


Step 1: You ask our plan to make a coverage decision on the medical care you are requesting. If your health requires a quick response, you should ask us to make a “fast coverage decision.”

Legal Terms

A “fast coverage decision” is called an

“expedited determination.”

Section 6.2 Step-by-step: How to ask for a coverage decision (how to ask our plan to authorize or provide the medical care coverage you want)

Legal Terms

When a coverage decision involves your

medical care, it is called an “organization determination.”



How to request coverage for the medical care you want

• Start by calling, writing, or faxing our plan to make your request for us to

authorize or provide coverage for the medical care you want. You, your doctor, or

your representative can do this.

• For the details on how to contact us, go to Chapter 2, Section 1 and look for the

section called How to contact us when you are asking for a coverage decision

about your medical care.

Generally, we use the standard deadlines for giving you our decision

When we give you our decision, we will use the “standard” deadlines unless we have agreed

to use the “fast” deadlines. A standard coverage decision means we will give you an

answer within 14 calendar days after we receive your request.

• However, we can take up to 14 more calendar days if you ask for more time, or if

we need information (such as medical records from out-of-network providers) that

may benefit you. If we decide to take extra days to make the decision, we will tell you

in writing.

• If you believe we should not take extra days, you can file a “fast complaint” about

our decision to take extra days. When you file a fast complaint, we will give you

an answer to your complaint within 24 hours. (The process for making a complaint

is different from the process for coverage decisions and appeals. For more

information about the process for making complaints, including fast complaints,

see Section 11 of this chapter.)

If your health requires it, ask us to give you a “fast coverage decision”

• A fast coverage decision means we will answer within 72 hours.

o However, we can take up to 14 more calendar days if we find that some

information that may benefit you is missing (such as medical records from

out-of-network providers), or if you need time to get information to us for the

review. If we decide to take extra days, we will tell you in writing.

o If you believe we should not take extra days, you can file a “fast complaint” about our decision to take extra days. (For more information about the

process for making complaints, including fast complaints, see Section 11 of

this chapter.) We will call you as soon as we make the decision.

• To get a fast coverage decision, you must meet two requirements:

o You can get a fast coverage decision only if you are asking for coverage for

medical care you have not yet received. (You cannot get a fast coverage

decision if your request is about payment for medical care you have already

received.)

o You can get a fast coverage decision only if using the standard deadlines

could cause serious harm to your health or hurt your ability to function.



• If your doctor tells us that your health requires a “fast coverage decision,” we will automatically agree to give you a fast coverage decision.

• If you ask for a fast coverage decision on your own, without your doctor’s support,

we will decide whether your health requires that we give you a fast coverage

decision.

o If we decide that your medical condition does not meet the requirements for a

fast coverage decision, we will send you a letter that says so (and we will use

the standard deadlines instead).

o This letter will tell you that if your doctor asks for the fast coverage decision,

we will automatically give a fast coverage decision.

o The letter will also tell how you can file a “fast complaint” about our decision

to give you a standard coverage decision instead of the fast coverage decision

you requested. (For more information about the process for making complaints,

including fast complaints, see Section 11 of this chapter.)

Step 2: We consider your request for medical care coverage and give you our answer.

Deadlines for a “fast” coverage decision

• Generally, for a fast coverage decision, we will give you our answer within 72 hours.

o As explained above, we can take up to 14 more calendar days under certain

circumstances. If we decide to take extra days to make the coverage decision,

we will tell you in writing.

o If you believe we should not take extra days, you can file a “fast complaint” about our decision to take extra days. When you file a fast complaint, we will

give you an answer to your complaint within 24 hours. (For more information

about the process for making complaints, including fast complaints, see Section

11 of this chapter.)

o If we do not give you our answer within 72 hours (or if there is an extended

time period, by the end of that period), you have the right to appeal. Section 6.3

below tells how to make an appeal.

• If our answer is yes to part or all of what you requested, we must authorize or

provide the medical care coverage we have agreed to provide within 72 hours after

we received your request. If we extended the time needed to make our coverage

decision, we will authorize or provide the coverage by the end of that extended

period.

• If our answer is no to part or all of what you requested, we will send you a

detailed written explanation as to why we said no.

Deadlines for a “standard” coverage decision

• Generally, for a standard coverage decision, we will give you our answer within 14

calendar days of receiving your request.



o We can take up to 14 more calendar days (“an extended time period”) under

certain circumstances. If we decide to take extra days to make the coverage

decision, we will tell you in writing.





o If we do not give you our answer within 14 calendar days (or if there is an

extended time period, by the end of that period), you have the right to appeal.

Section 6.3 below tells how to make an appeal.


provide the coverage we have agreed to provide within 14 calendar days after we

received your request. If we extended the time needed to make our coverage decision,

we will authorize or provide the coverage by the end of that extended period.

• If our answer is no to part or all of what you requested, we will send you a written

statement that explains why we said no.

Step 3: If we say no to your request for coverage for medical care, you decide if you want to make an appeal.

• If we say no, you have the right to ask us to reconsider – and perhaps change – this

decision by making an appeal. Making an appeal means making another try to get the

medical care coverage you want.

• If you decide to make an appeal, it means you are going on to Level 1 of the appeals

process (see Section 6.3 below).

Section 6.3 Step-by-step: How to make a Level 1 Appeal (How to ask for a review of a medical care coverage decision made by our plan)

Legal Terms

An appeal to the plan about a medical care

coverage decision is called a plan

“reconsideration.”

Step 1: You contact us and make your appeal. If your health requires a quick response, you must ask for a “fast appeal.”

What to do

• To start an appeal you, your doctor, or your representative, must contact us.

For details on how to reach us for any purpose related to your appeal, go to



Chapter 2, Section 1 and look for the section called How to contact us when you

are making an appeal about your medical care.

• If you are asking for a standard appeal, make your standard appeal in writing

by submitting a request. You may also ask for an appeal by calling us at the

phone number shown in Chapter 2, Section 1 (How to contact us when you are

making an appeal about your medical care).

o If you have someone appealing our decision for you other than your doctor,

your appeal must include an Appointment of Representative form authorizing

this person to represent you. (To get the form, call Member Services (phone

numbers are printed on the back cover of this booklet) and ask for the

“Appointment of Representative” form. It is also available on Medicare’s

website at https://www.cms.hhs.gov/cmsforms/downloads/cms1696.pdf or

on our website at www.metroplusmedicare.org.) While we can accept an

appeal request without the form, we cannot begin or complete our review

until we receive it. If we do not receive the form within 44 calendar days

after receiving your appeal request (our deadline for making a decision on

your appeal), your appeal request will be dismissed. If this happens, we will

send you a written notice explaining your right to ask the Independent

Review Organization to review our decision to dismiss your appeal.

• If you are asking for a fast appeal, make your appeal in writing or call us at

the phone number shown in Chapter 2, Section 1 (How to contact us when you are

making an appeal about your medical care).

• You must make your appeal request within 60 calendar days from the date on

the written notice we sent to tell you our answer to your request for a coverage

decision. If you miss this deadline and have a good reason for missing it, we may

give you more time to make your appeal. Examples of good cause for missing the

deadline may include if you had a serious illness that prevented you from

contacting us or if we provided you with incorrect or incomplete information about

the deadline for requesting an appeal.

• You can ask for a copy of the information regarding your medical decision

and add more information to support your appeal.

o You have the right to ask us for a copy of the information regarding your

appeal. We are allowed to charge a fee for copying and sending this

information to you.

o If you wish, you and your doctor may give us additional information to

support your appeal.

If your health requires it, ask for a “fast appeal” (you can make a request by calling us)

Legal Terms

A “fast appeal” is also called an

“expedited reconsideration.”

https://www.cms.hhs.gov/cmsforms/downloads/cms1696.pdf




• If you are appealing a decision we made about coverage for care you have not yet

received, you and/or your doctor will need to decide if you need a “fast appeal.”

• The requirements and procedures for getting a “fast appeal” are the same as those for getting a “fast coverage decision.” To ask for a fast appeal, follow the instructions for asking for a fast coverage decision. (These instructions are given earlier in this

section.)

• If your doctor tells us that your health requires a “fast appeal,” we will give you a fast

appeal.

Step 2: We consider your appeal and we give you our answer.

• When we are reviewing your appeal, we take another careful look at all of the

information about your request for coverage of medical care. We check to see if we

were following all the rules when we said no to your request.

• We will gather more information if we need it. We may contact you or your doctor to

get more information.

Deadlines for a “fast” appeal

• When we are using the fast deadlines, we must give you our answer within 72 hours

after we receive your appeal. We will give you our answer sooner if your health

requires us to do so.

o However, if you ask for more time, or if we need to gather more information

that may benefit you, we can take up to 14 more calendar days. If we decide

to take extra days to make the decision, we will tell you in writing.

o If we do not give you an answer within 72 hours (or by the end of the extended

time period if we took extra days), we are required to automatically send your

request on to Level 2 of the appeals process, where it will be reviewed by an

independent organization. Later in this section, we tell you about this

organization and explain what happens at Level 2 of the appeals process.


provide the coverage we have agreed to provide within 72 hours after we receive your

appeal.

• If our answer is no to part or all of what you requested, we will automatically

send your appeal to the Independent Review Organization for a Level 2 Appeal.

Deadlines for a “standard” appeal

• If we are using the standard deadlines, we must give you our answer within 30

calendar days after we receive your appeal if your appeal is about coverage for

services you have not yet received. We will give you our decision sooner if your

health condition requires us to.

o However, if you ask for more time, or if we need to gather more information

that may benefit you, we can take up to 14 more calendar days. If we decide

to take extra days to make the decision, we will tell you in writing.







o If we do not give you an answer by the deadline above (or by the end of the

extended time period if we took extra days), we are required to send your


independent outside organization. Later in this section, we talk about this review

organization and explain what happens at Level 2 of the appeals process.


provide the coverage we have agreed to provide within 30 calendar days after we

receive your appeal.

• If our answer is no to part or all of what you requested, we will automatically

send your appeal to the Independent Review Organization for a Level 2 Appeal.

Step 3: If our plan says no to part or all of your appeal, your case will automatically be sent on to the next level of the appeals process.

• To make sure we were following all the rules when we said no to your appeal, we are

required to send your appeal to the “Independent Review Organization.” When

we do this, it means that your appeal is going on to the next level of the appeals

process, which is Level 2.

Section 6.4 Step-by-step: How a Level 2 Appeal is done

If we say no to your Level 1 Appeal, your case will automatically be sent on to the next level of

the appeals process. During the Level 2 Appeal, the Independent Review Organization reviews

our decision for your first appeal. This organization decides whether the decision we made

should be changed.

Legal Terms

The formal name for the “Independent

Review Organization” is the “Independent

Review Entity.” It is sometimes called the

“IRE.”

Step 1: The Independent Review Organization reviews your appeal.

• The Independent Review Organization is an independent organization that is

hired by Medicare. This organization is not connected with us and it is not a

government agency. This organization is a company chosen by Medicare to handle

the job of being the Independent Review Organization. Medicare oversees its work.



• We will send the information about your appeal to this organization. This information

is called your “case file.” You have the right to ask us for a copy of your case file.

We are allowed to charge you a fee for copying and sending this information to you.

• You have a right to give the Independent Review Organization additional information

to support your appeal.

• Reviewers at the Independent Review Organization will take a careful look at all of

the information related to your appeal.

If you had a “fast” appeal at Level 1, you will also have a “fast” appeal at Level 2

• If you had a fast appeal to our plan at Level 1, you will automatically receive a fast

appeal at Level 2. The review organization must give you an answer to your Level 2

Appeal within 72 hours of when it receives your appeal.

• However, if the Independent Review Organization needs to gather more information

that may benefit you, it can take up to 14 more calendar days.

If you had a “standard” appeal at Level 1, you will also have a “standard” appeal at

Level 2

• If you had a standard appeal to our plan at Level 1, you will automatically receive a

standard appeal at Level 2. The review organization must give you an answer to your

Level 2 Appeal within 30 calendar days of when it receives your appeal.

• However, if the Independent Review Organization needs to gather more information

that may benefit you, it can take up to 14 more calendar days.

Step 2: The Independent Review Organization gives you their answer.

The Independent Review Organization will tell you its decision in writing and explain the

reasons for it.

• If the review organization says yes to part or all of what you requested, we must

authorize the medical care coverage within 72 hours or provide the service within 14

calendar days after we receive the decision from the review organization for standard

requests or within 72 hours from the date the plan receives the decision from the

review organization for expedited requests.

• If this organization says no to part or all of your appeal, it means they agree with

our plan that your request (or part of your request) for coverage for medical care

should not be approved. (This is called “upholding the decision.” It is also called

“turning down your appeal.”)

o If the Independent Review Organization “upholds the decision” you have the

right to a Level 3 Appeal. However, to make another appeal at Level 3, the

dollar value of the medical care coverage you are requesting must meet a

certain minimum. If the dollar value of the coverage you are requesting is too

low, you cannot make another appeal, which means that the decision at Level

2 is final. The written notice you get from the Independent Review



Organization will tell you how to find out the dollar amount to continue the

appeals process.

Step 3: If your case meets the requirements, you choose whether you want to take your appeal further.

• There are three additional levels in the appeals process after Level 2 (for a total of

five levels of appeal).

• If your Level 2 Appeal is turned down and you meet the requirements to continue

with the appeals process, you must decide whether you want to go on to Level 3 and

make a third appeal. The details on how to do this are in the written notice you got

after your Level 2 Appeal.

• The Level 3 Appeal is handled by an Administrative Law Judge or attorney

adjudicator. Section 10 in this chapter tells more about Levels 3, 4, and 5 of the

appeals process.

Section 6.5 What if you are asking us to pay you back for our share of a bill you have received for medical care?

If you want to ask us for payment for medical care, start by reading Chapter 7 of this booklet:

Asking us to pay our share of a bill you have received for covered medical services or drugs.

Chapter 7 describes the situations in which you may need to ask for reimbursement or to pay a

bill you have received from a provider. It also tells how to send us the paperwork that asks us for

payment.

Asking for reimbursement is asking for a coverage decision from us

If you send us the paperwork that asks for reimbursement, you are asking us to make a coverage

decision (for more information about coverage decisions, see Section 5.1 of this chapter). To

make this coverage decision, we will check to see if the medical care you paid for is a covered

service (see Chapter 4: Benefits Chart (what is covered and what you pay)). We will also check

to see if you followed all the rules for using your coverage for medical care (these rules are

given in Chapter 3 of this booklet: Using the plan’s coverage for your medical services).

We will say yes or no to your request

• If the medical care you paid for is covered and you followed all the rules, we will send

you the payment for our share of the cost of your medical care within 60 calendar days

after we receive your request. Or, if you haven’t paid for the services, we will send the payment directly to the provider. When we send the payment, it’s the same as saying yes

to your request for a coverage decision.)

• If the medical care is not covered, or you did not follow all the rules, we will not send

payment. Instead, we will send you a letter that says we will not pay for the services and

the reasons why in detail. (When we turn down your request for payment, it’s the same as

saying no to your request for a coverage decision.)



What if you ask for payment and we say that we will not pay?

If you do not agree with our decision to turn you down, you can make an appeal. If you make

an appeal, it means you are asking us to change the coverage decision we made when we turned

down your request for payment.

To make this appeal, follow the process for appeals that we describe in Section 5.3. Go to

this section for step-by-step instructions. When you are following these instructions, please note:

• If you make an appeal for reimbursement, we must give you our answer within 60

calendar days after we receive your appeal. (If you are asking us to pay you back for

medical care you have already received and paid for yourself, you are not allowed to ask

for a fast appeal.)

• If the Independent Review Organization reverses our decision to deny payment, we must

send the payment you have requested to you or to the provider within 30 calendar days. If

the answer to your appeal is yes at any stage of the appeals process after Level 2, we

must send the payment you requested to you or to the provider within 60 calendar days.

SECTION 7 Your Part B and Part D prescription drugs: How to ask for a coverage decision or make an appeal

Have you read Section 5 of this chapter (A guide to “the basics” of

coverage decisions and appeals)? If not, you may want to read it before you start this section.

Section 7.1 This section tells you what to do if you have problems getting a Part D drug or you want us to pay you back for a Part D drug

Your benefits as a member of our plan include coverage for many prescription drugs. Please

refer to our plan’s List of Covered Drugs (Formulary). To be covered, the drug must be used for

a medically accepted indication. (A “medically accepted indication” is a use of the drug that is

either approved by the Food and Drug Administration or supported by certain reference books.

See Chapter 5, Section 3 for more information about a medically accepted indication.)

Part B and Part D coverage decisions and appeals

As discussed in Section 5 of this chapter, a coverage decision is a decision we make about your

benefits and coverage or about the amount we will pay for your drugs.

Legal Terms

An initial coverage decision about your

drugs is called a “coverage determination.”



Here are examples of coverage decisions you ask us to make about your Part B and Part D drugs:

• You ask us to make an exception, including:

o Asking us to cover a drug that is not on the plan’s List of Covered Drugs

(Formulary)

o Asking us to waive a restriction on the plan’s coverage for a drug (such as limits

on the amount of the drug you can get)

o Asking to pay a lower cost-sharing amount for a covered drug on a higher cost-

sharing tier

• You ask us whether a drug is covered for you and whether you meet the requirements for

coverage. (For example, when your drug is on the plan’s List of Covered Drugs

(Formulary) but we require you to get approval from us before we will cover it for you.)

o Please note: If your pharmacy tells you that your prescription cannot be filled as

written, you will get a written notice explaining how to contact us to ask for a

coverage decision.

• You ask us to pay for a prescription drug you already bought. This is a request for a

coverage decision about payment.

If you disagree with a coverage decision we have made, you can appeal our decision.

This section tells you both how to ask for coverage decisions and how to request an appeal. Use

the chart below to help you determine which part has information for your situation:

Which of these situations are you in?

If you are in this situation: This is what you can do:

Do you need a drug that isn’t on our Drug List or need us to waive a rule or

restriction on a drug we cover?

You can ask us to make an exception. (This is a

type of coverage decision.)

Start with Section 7.2 of this chapter.

Do you want us to cover a drug on our

Drug List and you believe you meet any

plan rules or restrictions (such as getting

approval in advance) for the drug you

need?

You can ask us for a coverage decision.


Do you want to ask us to pay you back for

a drug you have already received and paid

for?

You can ask us to pay you back. (This is a type

of coverage decision.)


Have we already told you that we will not

cover or pay for a drug in the way that

you want it to be covered or paid for?

You can make an appeal. (This means you are

asking us to reconsider.)




Section 7.2 What is an exception?

If a drug is not covered in the way you would like it to be covered, you can ask us to make an

“exception.” An exception is a type of coverage decision. Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision.

When you ask for an exception, your doctor or other prescriber will need to explain the medical

reasons why you need the exception approved. We will then consider your request. Here are

three examples of exceptions that you or your doctor or other prescriber can ask us to make:

1. Covering a Part D drug for you that is not on our List of Covered Drugs (Formulary).

(We call it the “Drug List” for short.)

Legal Terms

Asking for coverage of a drug that is not on

the Drug List is sometimes called asking

for a “formulary exception.”

• If we agree to make an exception and cover a drug that is not on the Drug List, you

will need to pay the cost-sharing amount that applies to drugs in Tier 2 for brand

name drugs or Tier 1 for generic drugs. You cannot ask for an exception to the

copayment or coinsurance amount we require you to pay for the drug.

2. Removing a restriction on our coverage for a covered drug. There are extra rules or

restrictions that apply to certain drugs on our List of Covered Drugs (Formulary) (for more

information, go to Chapter 5 and look for Section 4).

Legal Terms

Asking for removal of a restriction on

coverage for a drug is sometimes called

asking for a “formulary exception.”

• The extra rules and restrictions on coverage for certain drugs include:

o Being required to use the generic version of a drug instead of the brand name

drug.

o Getting plan approval in advance before we will agree to cover the drug for

you. (This is sometimes called “prior authorization.”)

o Being required to try a different drug first before we will agree to cover the

drug you are asking for. (This is sometimes called “step therapy.”)

o Quantity limits. For some drugs, there are restrictions on the amount of the

drug you can have.

• If we agree to make an exception and waive a restriction for you, you can ask for an

exception to the copayment or coinsurance amount we require you to pay for the

drug.



3. Changing coverage of a drug to a lower cost-sharing tier. Every drug on our Drug List

is in one of two cost-sharing tiers. In general, the lower the cost-sharing tier number, the

less you will pay as your share of the cost of the drug.

Legal Terms

Asking to pay a lower price for a covered

non-preferred drug is sometimes called

asking for a “tiering exception.”

▪ If our drug list contains alternative drug(s) for treating your medical

condition that are in a lower cost-sharing tier than your drug, you can ask

us to cover your drug at the cost-sharing amount that applies to the

alternative drug(s). This would lower your share of the cost for the drug.

▪ If the drug you’re taking is a brand name drug you can ask us to cover

your drug at the cost-sharing amount that applies to the lowest tier that

contains brand name alternatives for treating your condition.

▪ If the drug you’re taking is a generic drug you can ask us to cover your

drug at the cost-sharing amount that applies to the lowest tier that contains

either brand or generic alternatives for treating your condition.

Section 7.3 Important things to know about asking for exceptions

Your doctor must tell us the medical reasons

Your doctor or other prescriber must give us a statement that explains the medical reasons for

requesting an exception. For a faster decision, include this medical information from your doctor

or other prescriber when you ask for the exception.

Typically, our Drug List includes more than one drug for treating a particular condition. These

different possibilities are called “alternative” drugs. If an alternative drug would be just as

effective as the drug you are requesting and would not cause more side effects or other health

problems, we will generally not approve your request for an exception. If you ask us for a tiering

exception, we will generally not approve your request for an exception unless all the alternative

drugs in the lower cost-sharing tier(s) won’t work as well for you.

We can say yes or no to your request

• If we approve your request for an exception, our approval usually is valid until the end of

the plan year. This is true as long as your doctor continues to prescribe the drug for you

and that drug continues to be safe and effective for treating your condition.

• If we say no to your request for an exception, you can ask for a review of our decision by

making an appeal. Section 7.5 tells how to make an appeal if we say no.

The next section tells you how to ask for a coverage decision, including an exception.



Section 7.4 Step-by-step: How to ask for a coverage decision, including an exception

Step 1: You ask us to make a coverage decision about the drug(s) or payment you need. If your health requires a quick response, you must ask us to make a “fast coverage decision.” You cannot ask for a fast coverage decision if you are asking us to pay you back for a drug you already bought.

What to do

• Request the type of coverage decision you want. Start by calling, writing, or

faxing us to make your request. You, your representative, or your doctor (or other

prescriber) can do this. You can also access the coverage decision process through

our website. For the details, go to Chapter 2, Section 1 and look for the section

called How to contact us when you are asking for a coverage decision about your

prescription drugs. Or if you are asking us to pay you back for a drug, go to the

section called Where to send a request that asks us to pay for our share of the cost

for medical care or a drug you have received.

• You or your doctor or someone else who is acting on your behalf can ask for a

coverage decision. Section 5 of this chapter tells how you can give written

permission to someone else to act as your representative. You can also have a

lawyer act on your behalf.

• If you want to ask us to pay you back for a drug, start by reading Chapter 7 of

this booklet: Asking us to pay our share of a bill you have received for covered

medical services or drugs. Chapter 7 describes the situations in which you may

need to ask for reimbursement. It also tells how to send us the paperwork that asks

us to pay you back for our share of the cost of a drug you have paid for.

• If you are requesting an exception, provide the “supporting statement.” Your

doctor or other prescriber must give us the medical reasons for the drug exception

you are requesting. (We call this the “supporting statement.”) Your doctor or other

prescriber can fax or mail the statement to us. Or your doctor or other prescriber

can tell us on the phone and follow up by faxing or mailing a written statement if

necessary. See Sections 6.2 and 6.3 for more information about exception requests.

• We must accept any written request, including a request submitted on the CMS

Model Coverage Determination Request Form or on our plan’s form, which are available on our website.

If your health requires it, ask us to give you a “fast coverage decision”

Legal Terms

A “fast coverage decision” is called an

“expedited coverage determination.”

• When we give you our decision, we will use the “standard” deadlines unless we have agreed to use the “fast” deadlines. A standard coverage decision means we



will give you an answer within 72 hours after we receive your doctor’s statement.

A fast coverage decision means we will answer within 24 hours after we receive

your doctor’s statement.

• To get a fast coverage decision, you must meet two requirements:

o You can get a fast coverage decision only if you are asking for a drug you have

not yet received. (You cannot get a fast coverage decision if you are asking us

to pay you back for a drug you have already bought.)

o You can get a fast coverage decision only if using the standard deadlines could

cause serious harm to your health or hurt your ability to function.

• If your doctor or other prescriber tells us that your health requires a “fast

coverage decision,” we will automatically agree to give you a fast coverage

decision.

• If you ask for a fast coverage decision on your own (without your doctor’s or other

prescriber’s support), we will decide whether your health requires that we give you a fast coverage decision.

o If we decide that your medical condition does not meet the requirements for a

fast coverage decision, we will send you a letter that says so (and we will use

the standard deadlines instead).

o This letter will tell you that if your doctor or other prescriber asks for the fast

coverage decision, we will automatically give a fast coverage decision.

o The letter will also tell how you can file a complaint about our decision to give

you a standard coverage decision instead of the fast coverage decision you

requested. It tells how to file a “fast” complaint, which means you would get

our answer to your complaint within 24 hours of receiving the complaint. (The

process for making a complaint is different from the process for coverage

decisions and appeals. For more information about the process for making

complaints, see Section 11 of this chapter.)

Step 2: We consider your request and we give you our answer.

Deadlines for a “fast” coverage decision

• If we are using the fast deadlines, we must give you our answer within 24

hours.

o Generally, this means within 24 hours after we receive your request. If you are

requesting an exception, we will give you our answer within 24 hours after we

receive your doctor’s statement supporting your request. We will give you our

answer sooner if your health requires us to.

o If we do not meet this deadline, we are required to send your request on to Level

2 of the appeals process, where it will be reviewed by an independent outside

organization. Later in this section, we talk about this review organization and

explain what happens at Appeal Level 2.



• If our answer is yes to part or all of what you requested, we must provide the

coverage we have agreed to provide within 24 hours after we receive your request or

doctor’s statement supporting your request.


statement that explains why we said no. We will also tell you how to appeal.

Deadlines for a “standard” coverage decision about a drug you have not yet received


hours.

o Generally, this means within 72 hours after we receive your request. If you are

requesting an exception, we will give you our answer within 72 hours after we

receive your doctor’s statement supporting your request. We will give you our

answer sooner if your health requires us to.


2 of the appeals process, where it will be reviewed by an independent



• If our answer is yes to part or all of what you requested –

o If we approve your request for coverage, we must provide the coverage we

have agreed to provide within 72 hours after we receive your request or

doctor’s statement supporting your request.



Deadlines for a “standard” coverage decision about payment for a drug you have already bought

• We must give you our answer within 14 calendar days after we receive your request.


2 of the appeals process, where it will be reviewed by an independent



• If our answer is yes to part or all of what you requested, we are also required to

make payment to you within 14 calendar days after we receive your request.



Step 3: If we say no to your coverage request, you decide if you want to make an appeal.

• If we say no, you have the right to request an appeal. Requesting an appeal means

asking us to reconsider – and possibly change – the decision we made.



Section 7.5 Step-by-step: How to make a Level 1 Appeal (how to ask for a review of a coverage decision made by our plan)

Legal Terms

An appeal to the plan about a drug

coverage decision is called a plan

“redetermination.”

Step 1: You contact us and make your Level 1 Appeal. If your health requires a quick response, you must ask for a “fast appeal.”

What to do

• To start your appeal, you (or your representative or your doctor or other

prescriber) must contact us.

o For details on how to reach us by phone, fax, or mail, or on our website for

any purpose related to your appeal, go to Chapter 2, Section 1, and look for

the section called How to contact us when you are making an appeal about

your Part B and Part D prescription drugs.

• If you are asking for a standard appeal, make your appeal by submitting a

written request. You may also ask for an appeal by calling us at the phone

number shown in Chapter 2, Section 1 (How to contact our plan when you are

making an appeal about your Part B and Part D prescription drugs).

• If you are asking for a fast appeal, you may make your appeal in writing or

you may call us at the phone number shown in Chapter 2, Section 1 (How to

contact our plan when you are making an appeal about your Part B and Part D

prescription drugs).

• We must accept any written request, including a request submitted on the CMS

Model Coverage Determination Request Form, which is available on our website.

• You must make your appeal request within 60 calendar days from the date on

the written notice we sent to tell you our answer to your request for a coverage

decision. If you miss this deadline and have a good reason for missing it, we may

give you more time to make your appeal. Examples of good cause for missing the

deadline may include if you had a serious illness that prevented you from

contacting us or if we provided you with incorrect or incomplete information about

the deadline for requesting an appeal.

• You can ask for a copy of the information in your appeal and add more

information.

o You have the right to ask us for a copy of the information regarding your

appeal. We are allowed to charge a fee for copying and sending this

information to you.



o If you wish, you and your doctor or other prescriber may give us additional

information to support your appeal.

If your health requires it, ask for a “fast appeal”

Legal Terms

A “fast appeal” is also called an “expedited redetermination.”

• If you are appealing a decision we made about a drug you have not yet received, you

and your doctor or other prescriber will need to decide if you need a “fast appeal.”

• The requirements for getting a “fast appeal” are the same as those for getting a “fast coverage decision” in Section 7.4 of this chapter.

Step 2: We consider your appeal and we give you our answer.

• When we are reviewing your appeal, we take another careful look at all of the

information about your coverage request. We check to see if we were following all the

rules when we said no to your request. We may contact you or your doctor or other

prescriber to get more information.

Deadlines for a “fast” appeal

• If we are using the fast deadlines, we must give you our answer within 72 hours

after we receive your appeal. We will give you our answer sooner if your health

requires it.

o If we do not give you an answer within 72 hours, we are required to send your


Independent Review Organization. Later in this section, we talk about this

review organization and explain what happens at Level 2 of the appeals process.

• If our answer is yes to part or all of what you requested, we must provide the

coverage we have agreed to provide within 72 hours after we receive your appeal.


statement that explains why we said no and how to appeal our decision.

Deadlines for a “standard” appeal


calendar days after we receive your appeal for a drug you have not received yet. We

will give you our decision sooner if you have not received the drug yet and your

health condition requires us to do so. If you believe your health requires it, you

should ask for “fast” appeal.

o If we do not give you a decision within 7 calendar days, we are required to send

your request on to Level 2 of the appeals process, where it will be reviewed by

an Independent Review Organization. Later in this section, we tell about this

review organization and explain what happens at Level 2 of the appeals process.



• If our answer is yes to part or all of what you requested –

o If we approve a request for coverage, we must provide the coverage we have

agreed to provide as quickly as your health requires, but no later than 7

calendar days after we receive your appeal.

o If we approve a request to pay you back for a drug you already bought, we are

required to send payment to you within 30 calendar days after we receive

your appeal request.


statement that explains why we said no and how to appeal our decision.

• If you are requesting that we pay you back for a drug you have already bought, we

must give you our answer within 14 calendar days after we receive your request.

o If we do not give you a decision within 14 calendar days, we are required to

send your request on to Level 2 of the appeals process, where it will be

reviewed by an independent organization. Later in this section, we talk about

this review organization and explain what happens at Appeal Level 2.

• If our answer is yes to part or all of what you requested, we are also required to

make payment to you within 30 calendar days after we receive your request.



Step 3: If we say no to your appeal, you decide if you want to continue with the appeals process and make another appeal.

• If we say no to your appeal, you then choose whether to accept this decision or

continue by making another appeal.

• If you decide to make another appeal, it means your appeal is going on to Level 2 of

the appeals process (see below).

Section 7.6 Step-by-step: How to make a Level 2 Appeal

If we say no to your appeal, you then choose whether to accept this decision or continue by

making another appeal. If you decide to go on to a Level 2 Appeal, the Independent Review

Organization reviews the decision we made when we said no to your first appeal. This

organization decides whether the decision we made should be changed.

Legal Terms




“IRE.”



Step 1: To make a Level 2 Appeal, you (or your representative or your doctor or other prescriber) must contact the Independent Review Organization and ask for a review of your case.

• If we say no to your Level 1 Appeal, the written notice we send you will include

instructions on how to make a Level 2 Appeal with the Independent Review

Organization. These instructions will tell who can make this Level 2 Appeal, what

deadlines you must follow, and how to reach the review organization.

• When you make an appeal to the Independent Review Organization, we will send the

information we have about your appeal to this organization. This information is called

your “case file.” You have the right to ask us for a copy of your case file. We are

allowed to charge you a fee for copying and sending this information to you.

• You have a right to give the Independent Review Organization additional information

to support your appeal.

Step 2: The Independent Review Organization does a review of your appeal and gives you an answer.


hired by Medicare. This organization is not connected with us and it is not a

government agency. This organization is a company chosen by Medicare to review

our decisions about your benefits with us.


the information related to your appeal. The organization will tell you its decision in

writing and explain the reasons for it.

Deadlines for “fast” appeal at Level 2

• If your health requires it, ask the Independent Review Organization for a “fast

appeal.”

• If the review organization agrees to give you a “fast appeal,” the review organization

must give you an answer to your Level 2 Appeal within 72 hours after it receives

your appeal request.

• If the Independent Review Organization says yes to part or all of what you

requested, we must provide the drug coverage that was approved by the review

organization within 24 hours after we receive the decision from the review

organization.

Deadlines for “standard” appeal at Level 2

• If you have a standard appeal at Level 2, the review organization must give you an

answer to your Level 2 Appeal within 7 calendar days after it receives your appeal if

it is for a drug you have not received yet. If you are requesting that we pay you back

for a drug you have already bought, the review organization must give you an answer

to your level 2 appeal within 14 calendar days after it receives your request.



• If the Independent Review Organization says yes to part or all of what you

requested –

o If the Independent Review Organization approves a request for coverage, we

must provide the drug coverage that was approved by the review organization

within 72 hours after we receive the decision from the review organization.

o If the Independent Review Organization approves a request to pay you back for

a drug you already bought, we are required to send payment to you within 30

calendar days after we receive the decision from the review organization.

What if the review organization says no to your appeal?

If this organization says no to your appeal, it means the organization agrees with our decision not

to approve your request. (This is called “upholding the decision.” It is also called “turning down

your appeal.”)

If the Independent Review Organization “upholds the decision” you have the right to a Level 3

appeal. However, to make another appeal at Level 3, the dollar value of the drug coverage you

are requesting must meet a minimum amount. If the dollar value of the drug coverage you are

requesting is too low, you cannot make another appeal and the decision at Level 2 is final. The

notice you get from the Independent Review Organization will tell you the dollar value that must

be in dispute to continue with the appeals process.

Step 3: If the dollar value of the coverage you are requesting meets the requirement, you choose whether you want to take your appeal further.


five levels of appeal).

• If your Level 2 Appeal is turned down and you meet the requirements to continue

with the appeals process, you must decide whether you want to go on to Level 3 and

make a third appeal. If you decide to make a third appeal, the details on how to do

this are in the written notice you got after your second appeal.

• The Level 3 Appeal is handled by an Administrative Law Judge or attorney

adjudicator. Section 10 in this chapter tells more about Levels 3, 4, and 5 of the

appeals process.

SECTION 8 How to ask us to cover a longer inpatient hospital stay if you think the doctor is discharging you too soon

When you are admitted to a hospital, you have the right to get all of your covered hospital

services that are necessary to diagnose and treat your illness or injury. For more information

about our coverage for your hospital care, including any limitations on this coverage, see Chapter

4 of this booklet: Benefits Chart (what is covered and what you pay).



During your covered hospital stay, your doctor and the hospital staff will be working with you to

prepare for the day when you will leave the hospital. They will also help arrange for care you

may need after you leave.

• The day you leave the hospital is called your “discharge date.”

• When your discharge date has been decided, your doctor or the hospital staff will let you

know.

• If you think you are being asked to leave the hospital too soon, you can ask for a longer

hospital stay and your request will be considered. This section tells you how to ask.

Section 8.1 During your inpatient hospital stay, you will get a written notice from Medicare that tells about your rights

During your covered hospital stay, you will be given a written notice called An Important

Message from Medicare about Your Rights. Everyone with Medicare gets a copy of this notice

whenever they are admitted to a hospital. Someone at the hospital (for example, a caseworker or

nurse) must give it to you within two days after you are admitted. If you do not get the notice,

ask any hospital employee for it. If you need help, please call Member Services (phone numbers

are printed on the back cover of this booklet). You can also call 1-800-MEDICARE (1-800-633-

4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.

1. Read this notice carefully and ask questions if you don’t understand it. It tells you

about your rights as a hospital patient, including:

• Your right to receive Medicare-covered services during and after your hospital stay,

as ordered by your doctor. This includes the right to know what these services are,

who will pay for them, and where you can get them.

• Your right to be involved in any decisions about your hospital stay, and know who

will pay for it

• Where to report any concerns you have about quality of your hospital care

• Your right to appeal your discharge decision if you think you are being discharged

from the hospital too soon

Legal Terms

The written notice from Medicare tells you

how you can “request an immediate review.” Requesting an immediate review

is a formal, legal way to ask for a delay in

your discharge date so that we will cover

your hospital care for a longer time.

(Section 8.2 below tells you how you can

request an immediate review.)



2. You must sign the written notice to show that you received it and understand your

rights.

• You or someone who is acting on your behalf must sign the notice. (Section 5 of this

chapter tells how you can give written permission to someone else to act as your

representative.)

• Signing the notice shows only that you have received the information about your

rights. The notice does not give your discharge date (your doctor or hospital staff will

tell you your discharge date). Signing the notice does not mean you are agreeing on

a discharge date.

3. Keep your copy of the signed notice so you will have the information about making

an appeal (or reporting a concern about quality of care) handy if you need it.

• If you sign the notice more than two days before the day you leave the hospital, you

will get another copy before you are scheduled to be discharged.

• To look at a copy of this notice in advance, you can call Member Services (phone

numbers are printed on the back cover of this booklet) or 1-800 MEDICARE (1-800-

633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.

You can also see it online at https://www.cms.gov/Medicare/Medicare-General-

Information/BNI/HospitalDischargeAppealNotices.html

Section 8.2 Step-by-step: How to make a Level 1 Appeal to change your hospital discharge date

If you want to ask for your inpatient hospital services to be covered by us for a longer time,

you will need to use the appeals process to make this request. Before you start, understand

what you need to do and what the deadlines are.

• Follow the process. Each step in the first two levels of the appeals process is

explained below.

• Meet the deadlines. The deadlines are important. Be sure that you understand and

follow the deadlines that apply to things you must do.

• Ask for help if you need it. If you have questions or need help at any time, please


Or call your State Health Insurance Assistance Program, a government organization

that provides personalized assistance (see Section 2 of this chapter).

During a Level 1 Appeal, the Quality Improvement Organization reviews your appeal. It

checks to see if your planned discharge date is medically appropriate for you.

https://www.cms.gov/Medicare/Medicare-General-Information/BNI/HospitalDischargeAppealNotices.html




Step 1: Contact the Quality Improvement Organization for your state and ask for a “fast review” of your hospital discharge. You must act quickly.

A “fast review” is also called an “immediate review.”

What is the Quality Improvement Organization?

• This organization is a group of doctors and other health care professionals who are

paid by the Federal government. These experts are not part of our plan. This

organization is paid by Medicare to check on and help improve the quality of care for

people with Medicare. This includes reviewing hospital discharge dates for people

with Medicare.

How can you contact this organization?

• The written notice you received (An Important Message from Medicare About Your

Rights) tells you how to reach this organization. (Or find the name, address, and

phone number of the Quality Improvement Organization for your state in Chapter 2,

Section 4, of this booklet.)

Act quickly:

• To make your appeal, you must contact the Quality Improvement Organization before

you leave the hospital and no later than your planned discharge date. (Your

“planned discharge date” is the date that has been set for you to leave the hospital.)

o If you meet this deadline, you are allowed to stay in the hospital after your

discharge date without paying for it while you wait to get the decision on your

appeal from the Quality Improvement Organization.

o If you do not meet this deadline, and you decide to stay in the hospital after

your planned discharge date, you may have to pay all of the costs for hospital

care you receive after your planned discharge date.

• If you miss the deadline for contacting the Quality Improvement Organization about

your appeal, you can make your appeal directly to our plan instead. For details about

this other way to make your appeal, see Section 8.4.

Ask for a “fast review”:

• You must ask the Quality Improvement Organization for a “fast review” of your

discharge. Asking for a “fast review” means you are asking for the organization to

use the “fast” deadlines for an appeal instead of using the standard deadlines.

Legal Terms

A “fast review” is also called an

“immediate review” or an “expedited

review.”



Step 2: The Quality Improvement Organization conducts an independent review of your case.

What happens during this review?

• Health professionals at the Quality Improvement Organization (we will call them “the reviewers” for short) will ask you (or your representative) why you believe coverage for the services should continue. You don’t have to prepare anything in writing, but

you may do so if you wish.

• The reviewers will also look at your medical information, talk with your doctor, and

review information that the hospital and we have given to them.

• By noon of the day after the reviewers informed our plan of your appeal, you

will also get a written notice that gives your planned discharge date and explains

in detail the reasons why your doctor, the hospital, and we think it is right

(medically appropriate) for you to be discharged on that date.

Legal Terms

This written explanation is called the “Detailed Notice

of Discharge.” You can get a sample of this notice by

calling Member Services (phone numbers are printed on

the back cover of this booklet) or 1-800-MEDICARE

(1-800-633-4227), 24 hours a day, 7 days a week. (TTY

users should call 1-877-486-2048.) Or you can see a

sample notice online at

https://www.cms.gov/Medicare/Medicare-General-

Information/BNI/HospitalDischargeAppealNotices.html

Step 3: Within one full day after it has all the needed information, the Quality Improvement Organization will give you its answer to your appeal.

What happens if the answer is yes?

• If the review organization says yes to your appeal, we must keep providing your

covered inpatient hospital services for as long as these services are medically

necessary.

• You will have to keep paying your share of the costs (such as deductibles or

copayments, if these apply). In addition, there may be limitations on your covered

hospital services. (See Chapter 4 of this booklet.)

What happens if the answer is no?

• If the review organization says no to your appeal, they are saying that your planned

discharge date is medically appropriate. If this happens, our coverage for your

inpatient hospital services will end at noon on the day after the Quality

Improvement Organization gives you its answer to your appeal.





• If the review organization says no to your appeal and you decide to stay in the

hospital, then you may have to pay the full cost of hospital care you receive after

noon on the day after the Quality Improvement Organization gives you its answer to

your appeal.

Step 4: If the answer to your Level 1 Appeal is no, you decide if you want to make another appeal.

• If the Quality Improvement Organization has turned down your appeal, and you stay

in the hospital after your planned discharge date, then you can make another appeal.

Making another appeal means you are going on to “Level 2” of the appeals process.

Section 8.3 Step-by-step: How to make a Level 2 Appeal to change your hospital discharge date

If the Quality Improvement Organization has turned down your appeal, and you stay in the

hospital after your planned discharge date, then you can make a Level 2 Appeal. During a Level

2 Appeal, you ask the Quality Improvement Organization to take another look at the decision

they made on your first appeal. If the Quality Improvement Organization turns down your Level

2 Appeal, you may have to pay the full cost for your stay after your planned discharge date.

Here are the steps for Level 2 of the appeal process:

Step 1: You contact the Quality Improvement Organization again and ask for another review.

• You must ask for this review within 60 calendar days after the day the Quality

Improvement Organization said no to your Level 1 Appeal. You can ask for this

review only if you stayed in the hospital after the date that your coverage for the care

ended.

Step 2: The Quality Improvement Organization does a second review of your situation.

• Reviewers at the Quality Improvement Organization will take another careful look at

all of the information related to your appeal.

Step 3: Within 14 calendar days of receipt of your request for a second review, the Quality Improvement Organization reviewers will decide on your appeal and tell you their decision.

If the review organization says yes:

• We must reimburse you for our share of the costs of hospital care you have received

since noon on the day after the date your first appeal was turned down by the Quality

Improvement Organization. We must continue providing coverage for your

inpatient hospital care for as long as it is medically necessary.



• You must continue to pay your share of the costs and coverage limitations may

apply.

If the review organization says no:

• It means they agree with the decision they made on your Level 1 Appeal and will not

change it.

• The notice you get will tell you in writing what you can do if you wish to continue

with the review process. It will give you the details about how to go on to the next

level of appeal, which is handled by an Administrative Law Judge or attorney

adjudicator.

Step 4: If the answer is no, you will need to decide whether you want to take your appeal further by going on to Level 3.

• There are three additional levels in the appeals process after Level 2 (for a total of five

levels of appeal). If the review organization turns down your Level 2 Appeal, you can

choose whether to accept that decision or whether to go on to Level 3 and make

another appeal. At Level 3, your appeal is reviewed by an Administrative Law Judge

or attorney adjudicator.

• Section 10 in this chapter tells more about Levels 3, 4, and 5 of the appeals process.

Section 8.4 What if you miss the deadline for making your Level 1 Appeal?

You can appeal to us instead

As explained above in Section 8.2, you must act quickly to contact the Quality Improvement

Organization to start your first appeal of your hospital discharge. (“Quickly” means before you

leave the hospital and no later than your planned discharge date.) If you miss the deadline for

contacting this organization, there is another way to make your appeal.

If you use this other way of making your appeal, the first two levels of appeal are different.

Step-by-Step: How to make a Level 1 Alternate Appeal

If you miss the deadline for contacting the Quality Improvement Organization, you can make an

appeal to us, asking for a “fast review.” A fast review is an appeal that uses the fast deadlines

instead of the standard deadlines.

Legal Terms

A “fast” review (or “fast appeal”) is also

called an “expedited appeal.”



Step 1: Contact us and ask for a “fast review.”

• For details on how to contact us, go to Chapter 2, Section 1 and look for the

section called, How to contact us when you are making an appeal about your

medical care.

• Be sure to ask for a “fast review.” This means you are asking us to give you an

answer using the “fast” deadlines rather than the “standard” deadlines.

Step 2: We do a “fast” review of your planned discharge date, checking to see if it was medically appropriate.

• During this review, we take a look at all of the information about your hospital stay.

We check to see if your planned discharge date was medically appropriate. We will

check to see if the decision about when you should leave the hospital was fair and

followed all the rules.

• In this situation, we will use the “fast” deadlines rather than the standard deadlines for giving you the answer to this review.

Step 3: We give you our decision within 72 hours after you ask for a “fast review” (“fast appeal”).

• If we say yes to your fast appeal, it means we have agreed with you that you still

need to be in the hospital after the discharge date, and will keep providing your

covered inpatient hospital services for as long as it is medically necessary. It also

means that we have agreed to reimburse you for our share of the costs of care you

have received since the date when we said your coverage would end. (You must pay

your share of the costs and there may be coverage limitations that apply.)

• If we say no to your fast appeal, we are saying that your planned discharge date was

medically appropriate. Our coverage for your inpatient hospital services ends as of the

day we said coverage would end.

o If you stayed in the hospital after your planned discharge date, then you may

have to pay the full cost of hospital care you received after the planned discharge

date.

Step 4: If we say no to your fast appeal, your case will automatically be sent on to the next level of the appeals process.

• To make sure we were following all the rules when we said no to your fast appeal, we

are required to send your appeal to the “Independent Review Organization.”

When we do this, it means that you are automatically going on to Level 2 of the

appeals process.

Step-by-Step: Level 2 Alternate Appeal Process


the appeals process. During the Level 2 Appeal, an Independent Review Organization reviews



the decision we made when we said no to your “fast appeal.” This organization decides whether

the decision we made should be changed.

Legal Terms




“IRE.”

Step 1: We will automatically forward your case to the Independent Review Organization.

• We are required to send the information for your Level 2 Appeal to the Independent

Review Organization within 24 hours of when we tell you that we are saying no to

your first appeal. (If you think we are not meeting this deadline or other deadlines,

you can make a complaint. The complaint process is different from the appeal

process. Section 11 of this chapter tells how to make a complaint.)

Step 2: The Independent Review Organization does a “fast review” of your appeal. The reviewers give you an answer within 72 hours.


hired by Medicare. This organization is not connected with our plan and it is not a




the information related to your appeal of your hospital discharge.

• If this organization says yes to your appeal, then we must reimburse you (pay you

back) for our share of the costs of hospital care you have received since the date of

your planned discharge. We must also continue the plan’s coverage of your inpatient

hospital services for as long as it is medically necessary. You must continue to pay

your share of the costs. If there are coverage limitations, these could limit how much

we would reimburse or how long we would continue to cover your services.

• If this organization says no to your appeal, it means they agree with us that your

planned hospital discharge date was medically appropriate.

o The notice you get from the Independent Review Organization will tell you in

writing what you can do if you wish to continue with the review process. It

will give you the details about how to go on to a Level 3 Appeal, which is

handled by an Administrative Law Judge or attorney adjudicator.



Step 3: If the Independent Review Organization turns down your appeal, you choose whether you want to take your appeal further.


five levels of appeal). If reviewers say no to your Level 2 Appeal, you decide whether

to accept their decision or go on to Level 3 and make a third appeal.


SECTION 9 How to ask us to keep covering certain medical services if you think your coverage is ending too soon

Section 9.1 This section is about three services only: Home health care, skilled nursing facility care, and Comprehensive Outpatient Rehabilitation Facility (CORF) services

This section is about the following types of care only:

• Home health care services you are getting

• Skilled nursing care you are getting as a patient in a skilled nursing facility. (To learn

about requirements for being considered a “skilled nursing facility,” see Chapter 12,

Definitions of important words.)

• Rehabilitation care you are getting as an outpatient at a Medicare-approved

Comprehensive Outpatient Rehabilitation Facility (CORF). Usually, this means you are

getting treatment for an illness or accident, or you are recovering from a major operation.

(For more information about this type of facility, see Chapter 12, Definitions of important

words.)

When you are getting any of these types of care, you have the right to keep getting your covered

services for that type of care for as long as the care is needed to diagnose and treat your illness or

injury. For more information on your covered services, including your share of the cost and any

limitations to coverage that may apply, see Chapter 4 of this booklet: Benefits Chart (what is

covered and what you pay).

When we decide it is time to stop covering any of the three types of care for you, we are required

to tell you in advance. When your coverage for that care ends, we will stop paying our share of

the cost for your care.

If you think we are ending the coverage of your care too soon, you can appeal our decision.

This section tells you how to ask for an appeal.



Section 9.2 We will tell you in advance when your coverage will be ending

1. You receive a notice in writing. At least two days before our plan is going to stop

covering your care, you will receive a notice.

• The written notice tells you the date when we will stop covering the care for you.

• The written notice also tells what you can do if you want to ask our plan to change

this decision about when to end your care, and keep covering it for a longer period of

time.

Legal Terms

In telling you what you can do, the written notice is

telling how you can request a “fast-track appeal.”

Requesting a fast-track appeal is a formal, legal way to

request a change to our coverage decision about when to

stop your care. (Section 9.3 below tells how you can

request a fast-track appeal.)

The written notice is called the “Notice of Medicare

Non-Coverage.” To get a sample copy, call Member

Services (phone numbers are printed on the back cover

of this booklet) or 1-800-MEDICARE (1-800-633-4227,

24 hours a day, 7 days a week. TTY users should call 1-

877-486-2048.). Or see a copy online at

https://www.cms.gov/Medicare/Medicare-General-

Information/BNI/MAEDNotices.html

2. You must sign the written notice to show that you received it.

• You or someone who is acting on your behalf must sign the notice. (Section 5 tells

how you can give written permission to someone else to act as your representative.)

• Signing the notice shows only that you have received the information about when

your coverage will stop. Signing it does not mean you agree with the plan that it’s

time to stop getting the care.

Section 9.3 Step-by-step: How to make a Level 1 Appeal to have our plan cover your care for a longer time

If you want to ask us to cover your care for a longer period of time, you will need to use the

appeals process to make this request. Before you start, understand what you need to do and

what the deadlines are.

• Follow the process. Each step in the first two levels of the appeals process is

explained below.

• Meet the deadlines. The deadlines are important. Be sure that you understand and

follow the deadlines that apply to things you must do. There are also deadlines our

https://www.cms.gov/Medicare/Medicare-General-Information/BNI/MAEDNotices.html

https://www.cms.gov/Medicare/Medicare-General-Information/BNI/MAEDNotices.html



plan must follow. (If you think we are not meeting our deadlines, you can file a

complaint. Section 11 of this chapter tells you how to file a complaint.)

• Ask for help if you need it. If you have questions or need help at any time, please


Or call your State Health Insurance Assistance Program, a government organization

that provides personalized assistance (see Section 2 of this chapter).

During a Level 1 Appeal, the Quality Improvement Organization reviews your appeal and

decides whether to change the decision made by our plan.

Step 1: Make your Level 1 Appeal: contact the Quality Improvement Organization for your state and ask for a review. You must act quickly.

What is the Quality Improvement Organization?

• This organization is a group of doctors and other health care experts who are paid by

the Federal government. These experts are not part of our plan. They check on the

quality of care received by people with Medicare and review plan decisions about

when it’s time to stop covering certain kinds of medical care.

How can you contact this organization?

• The written notice you received tells you how to reach this organization. (Or find the

name, address, and phone number of the Quality Improvement Organization for your

state in Chapter 2, Section 4 of this booklet.)

What should you ask for?

• Ask this organization for a “fast-track appeal” (to do an independent review) of

whether it is medically appropriate for us to end coverage for your medical services.

Your deadline for contacting this organization.

• You must contact the Quality Improvement Organization to start your appeal no later

than noon of the day after you receive the written notice telling you when we will

stop covering your care.

• If you miss the deadline for contacting the Quality Improvement Organization about

your appeal, you can make your appeal directly to us instead. For details about this

other way to make your appeal, see Section 9.5.

Step 2: The Quality Improvement Organization conducts an independent review of your case.

What happens during this review?

• Health professionals at the Quality Improvement Organization (we will call them “the reviewers” for short) will ask you (or your representative) why you believe coverage for the services should continue. You don’t have to prepare anything in writing, but

you may do so if you wish.



• The review organization will also look at your medical information, talk with your

doctor, and review information that our plan has given to them.

• By the end of the day the reviewers informed us of your appeal, and you will

also get a written notice from us that explains in detail our reasons for ending

our coverage for your services.

Legal Terms

This notice explanation is called the

“Detailed Explanation of Non-

Coverage.”

Step 3: Within one full day after they have all the information they need, the reviewers will tell you their decision.

What happens if the reviewers say yes to your appeal?

• If the reviewers say yes to your appeal, then we must keep providing your covered

services for as long as it is medically necessary.

• You will have to keep paying your share of the costs (such as deductibles or

copayments, if these apply). In addition, there may be limitations on your covered

services (see Chapter 4 of this booklet).

What happens if the reviewers say no to your appeal?

• If the reviewers say no to your appeal, then your coverage will end on the date we

have told you. We will stop paying our share of the costs of this care on the date listed

on the notice.

• If you decide to keep getting the home health care, or skilled nursing facility care, or

Comprehensive Outpatient Rehabilitation Facility (CORF) services after this date

when your coverage ends, then you will have to pay the full cost of this care

yourself.

Step 4: If the answer to your Level 1 Appeal is no, you decide if you want to make another appeal.

• This first appeal you make is “Level 1” of the appeals process. If reviewers say no to

your Level 1 Appeal – and you choose to continue getting care after your coverage

for the care has ended – then you can make another appeal.

• Making another appeal means you are going on to “Level 2” of the appeals process.

Section 9.4 Step-by-step: How to make a Level 2 Appeal to have our plan cover your care for a longer time

If the Quality Improvement Organization has turned down your appeal and you choose to

continue getting care after your coverage for the care has ended, then you can make a Level 2

Appeal. During a Level 2 Appeal, you ask the Quality Improvement Organization to take another



look at the decision they made on your first appeal. If the Quality Improvement Organization

turns down your Level 2 Appeal, you may have to pay the full cost for your home health care, or

skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF)

services after the date when we said your coverage would end.

Here are the steps for Level 2 of the appeal process:

Step 1: You contact the Quality Improvement Organization again and ask for another review.

• You must ask for this review within 60 days after the day when the Quality

Improvement Organization said no to your Level 1 Appeal. You can ask for this

review only if you continued getting care after the date that your coverage for the care

ended.

Step 2: The Quality Improvement Organization does a second review of your situation.

• Reviewers at the Quality Improvement Organization will take another careful look at

all of the information related to your appeal.

Step 3: Within 14 days of receipt of your appeal request, reviewers will decide on your appeal and tell you their decision.

What happens if the review organization says yes to your appeal?

• We must reimburse you for our share of the costs of care you have received since

the date when we said your coverage would end. We must continue providing

coverage for the care for as long as it is medically necessary.

• You must continue to pay your share of the costs and there may be coverage

limitations that apply.

What happens if the review organization says no?

• It means they agree with the decision we made to your Level 1 Appeal and will not

change it.

• The notice you get will tell you in writing what you can do if you wish to continue

with the review process. It will give you the details about how to go on to the next

level of appeal, which is handled by an Administrative Law Judge or attorney

adjudicator.

Step 4: If the answer is no, you will need to decide whether you want to take your appeal further.

• There are three additional levels of appeal after Level 2, for a total of five levels of

appeal. If reviewers turn down your Level 2 Appeal, you can choose whether to

accept that decision or to go on to Level 3 and make another appeal. At Level 3, your

appeal is reviewed by an Administrative Law Judge or attorney adjudicator.




Section 9.5 What if you miss the deadline for making your Level 1 Appeal?

You can appeal to us instead

As explained above in Section 9.3, you must act quickly to contact the Quality Improvement

Organization to start your first appeal (within a day or two, at the most). If you miss the deadline

for contacting this organization, there is another way to make your appeal. If you use this other

way of making your appeal, the first two levels of appeal are different.

Step-by-Step: How to make a Level 1 Alternate Appeal

If you miss the deadline for contacting the Quality Improvement Organization, you can make an

appeal to us, asking for a “fast review.” A fast review is an appeal that uses the fast deadlines

instead of the standard deadlines.

Here are the steps for a Level 1 Alternate Appeal:

Legal Terms

A “fast” review (or “fast appeal”) is also

called an “expedited appeal.”

Step 1: Contact us and ask for a “fast review.”

• For details on how to contact us, go to Chapter 2, Section 1 and look for the

section called How to contact us when you are making an appeal about your

medical care.

• Be sure to ask for a “fast review.” This means you are asking us to give you an

answer using the “fast” deadlines rather than the “standard” deadlines.

Step 2: We do a “fast” review of the decision we made about when to end coverage for your services.

• During this review, we take another look at all of the information about your case.

We check to see if we were following all the rules when we set the date for ending the

plan’s coverage for services you were receiving.

• We will use the “fast” deadlines rather than the standard deadlines for giving you the

answer to this review.

Step 3: We give you our decision within 72 hours after you ask for a “fast review” (“fast appeal”).

• If we say yes to your fast appeal, it means we have agreed with you that you need

services longer, and will keep providing your covered services for as long as it is

medically necessary. It also means that we have agreed to reimburse you for our share



of the costs of care you have received since the date when we said your coverage

would end. (You must pay your share of the costs and there may be coverage

limitations that apply.)

• If we say no to your fast appeal, then your coverage will end on the date we told

you and we will not pay any share of the costs after this date.

• If you continued to get home health care, or skilled nursing facility care, or

Comprehensive Outpatient Rehabilitation Facility (CORF) services after the date

when we said your coverage would end, then you will have to pay the full cost of

this care yourself.

Step 4: If we say no to your fast appeal, your case will automatically go on to the next level of the appeals process.

• To make sure we were following all the rules when we said no to your fast appeal, we

are required to send your appeal to the “Independent Review Organization.”

When we do this, it means that you are automatically going on to Level 2 of the

appeals process.

Step-by-Step: Level 2 Alternate Appeal Process


the appeals process. During the Level 2 Appeal, the Independent Review Organization reviews

the decision we made when we said no to your “fast appeal.” This organization decides whether

the decision we made should be changed.

Legal Terms

The formal name for the “Independent Review Organization” is the “Independent Review Entity.” It is sometimes called the “IRE.”

Step 1: We will automatically forward your case to the Independent Review Organization.

• We are required to send the information for your Level 2 Appeal to the Independent

Review Organization within 24 hours of when we tell you that we are saying no to

your first appeal. (If you think we are not meeting this deadline or other deadlines,

you can make a complaint. The complaint process is different from the appeal

process. Section 11 of this chapter tells how to make a complaint.)

Step 2: The Independent Review Organization does a “fast review” of your appeal. The reviewers give you an answer within 72 hours.


hired by Medicare. This organization is not connected with our plan and it is not a






the information related to your appeal.

• If this organization says yes to your appeal, then we must reimburse you (pay you

back) for our share of the costs of care you have received since the date when we said

your coverage would end. We must also continue to cover the care for as long as it is

medically necessary. You must continue to pay your share of the costs. If there are

coverage limitations, these could limit how much we would reimburse or how long

we would continue to cover your services.

• If this organization says no to your appeal, it means they agree with the decision

our plan made to your first appeal and will not change it.

o The notice you get from the Independent Review Organization will tell you in

writing what you can do if you wish to continue with the review process. It

will give you the details about how to go on to a Level 3 Appeal.

Step 3: If the Independent Review Organization turns down your appeal, you choose whether you want to take your appeal further.

• There are three additional levels of appeal after Level 2, for a total of five levels of

appeal. If reviewers say no to your Level 2 Appeal, you can choose whether to accept

that decision or whether to go on to Level 3 and make another appeal. At Level 3,

your appeal is reviewed by an Administrative Law Judge or attorney adjudicator.


SECTION 10 Taking your appeal to Level 3 and beyond

Section 10.1 Levels of Appeal 3, 4, and 5 for Medical Service Appeals

This section may be appropriate for you if you have made a Level 1 Appeal and a Level 2

Appeal, and both of your appeals have been turned down.

If the dollar value of the item or medical service you have appealed meets certain minimum

levels, you may be able to go on to additional levels of appeal. If the dollar value is less than the

minimum level, you cannot appeal any further. If the dollar value is high enough, the written

response you receive to your Level 2 Appeal will explain who to contact and what to do to ask

for a Level 3 Appeal.

For most situations that involve appeals, the last three levels of appeal work in much the same

way. Here is who handles the review of your appeal at each of these levels.

Level 3 Appeal A judge (called an Administrative Law Judge) or an attorney adjudicator

who works for the Federal government will review your appeal and give

you an answer.



• If the Administrative Law Judge or attorney adjudicator says yes to your appeal,

the appeals process may or may not be over - We will decide whether to appeal this

decision to Level 4. Unlike a decision at Level 2 (Independent Review Organization), we

have the right to appeal a Level 3 decision that is favorable to you.

o If we decide not to appeal the decision, we must authorize or provide you with the

service within 60 calendar days after receiving the Administrative Law Judge’s or

attorney adjudicator’s decision.

o If we decide to appeal the decision, we will send you a copy of the Level 4 Appeal

request with any accompanying documents. We may wait for the Level 4 Appeal

decision before authorizing or providing the service in dispute.

• If the Administrative Law Judge or attorney adjudicator says no to your appeal, the

appeals process may or may not be over.

o If you decide to accept this decision that turns down your appeal, the appeals

process is over.

o If you do not want to accept the decision, you can continue to the next level of the

review process. If the Administrative Law Judge or attorney adjudicator says no to

your appeal, the notice you get will tell you what to do next if you choose to

continue with your appeal.

Level 4 Appeal The Medicare Appeals Council (Council) will review your appeal and give

you an answer. The Council is part of the Federal government.

• If the answer is yes, or if the Council denies our request to review a favorable Level

3 Appeal decision, the appeals process may or may not be over - We will decide

whether to appeal this decision to Level 5. Unlike a decision at Level 2 (Independent

Review Organization), we have the right to appeal a Level 4 decision that is favorable to

you.

o If we decide not to appeal the decision, we must authorize or provide you with the

service within 60 calendar days after receiving the Council’s decision.

o If we decide to appeal the decision, we will let you know in writing.

• If the answer is no or if the Council denies the review request, the appeals process

may or may not be over.


process is over.

o If you do not want to accept the decision, you might be able to continue to the next

level of the review process. If the Council says no to your appeal, the notice you get

will tell you whether the rules allow you to go on to a Level 5 Appeal. If the rules

allow you to go on, the written notice will also tell you who to contact and what to

do next if you choose to continue with your appeal.

Level 5 Appeal A judge at the Federal District Court will review your appeal.



• This is the last step of the appeals process.

Section 10.2 Levels of Appeal 3, 4, and 5 for Part D Drug Appeals

This section may be appropriate for you if you have made a Level 1 Appeal and a Level 2

Appeal, and both of your appeals have been turned down.

If the value of the drug you have appealed meets a certain dollar amount, you may be able to go

on to additional levels of appeal. If the dollar amount is less, you cannot appeal any further. The

written response you receive to your Level 2 Appeal will explain who to contact and what to do

to ask for a Level 3 Appeal.

For most situations that involve appeals, the last three levels of appeal work in much the same

way. Here is who handles the review of your appeal at each of these levels.

Level 3 Appeal A judge (called an Administrative Law Judge) or attorney adjudicator

who works for the Federal government will review your appeal and give you

an answer.

• If the answer is yes, the appeals process is over. What you asked for in the appeal has

been approved. We must authorize or provide the drug coverage that was approved by

the Administrative Law Judge or attorney adjudicator within 72 hours (24 hours for

expedited appeals) or make payment no later than 30 calendar days after we receive

the decision.

• If the answer is no, the appeals process may or may not be over.


process is over.

o If you do not want to accept the decision, you can continue to the next level of the

review process. If the Administrative Law Judge or attorney adjudicator says no to

your appeal, the notice you get will tell you what to do next if you choose to

continue with your appeal.

Level 4 Appeal The Medicare Appeals Council (Council) will review your appeal and give

you an answer. The Council is part of the Federal government.

• If the answer is yes, the appeals process is over. What you asked for in the appeal has

been approved. We must authorize or provide the drug coverage that was approved by

the Council within 72 hours (24 hours for expedited appeals) or make payment no

later than 30 calendar days after we receive the decision.

• If the answer is no, the appeals process may or may not be over.


process is over.



o If you do not want to accept the decision, you might be able to continue to the next

level of the review process. If the Council says no to your appeal or denies your

request to review the appeal, the notice you get will tell you whether the rules allow

you to go on to a Level 5 Appeal. If the rules allow you to go on, the written notice

will also tell you who to contact and what to do next if you choose to continue with

your appeal.

Level 5 Appeal A judge at the Federal District Court will review your appeal.

• This is the last step of the appeals process.

SECTION 11 How to make a complaint about quality of care, waiting times, customer service, or other concerns

If your problem is about decisions related to benefits, coverage, or

payment, then this section is not for you. Instead, you need to use the process for coverage decisions and appeals. Go to Section 5 of this chapter.

Section 11.1 What kinds of problems are handled by the complaint process?

This section explains how to use the process for making complaints. The complaint process is

used for certain types of problems only. This includes problems related to quality of care,

waiting times, and the customer service you receive. Here are examples of the kinds of problems

handled by the complaint process.

If you have any of these kinds of problems, you can “make a complaint”

Complaint Example

Quality of your medical care • Are you unhappy with the quality of the care you

have received (including care in the hospital)?

Respecting your privacy • Do you believe that someone did not respect your

right to privacy or shared information about you that

you feel should be confidential?

Disrespect, poor customer

service, or other negative

behaviors

• Has someone been rude or disrespectful to you?

• Are you unhappy with how our Member Services has

treated you?

• Do you feel you are being encouraged to leave the

plan?



Complaint Example

Waiting times • Are you having trouble getting an appointment, or

waiting too long to get it?

• Have you been kept waiting too long by doctors,

pharmacists, or other health professionals? Or by our

Member Services or other staff at the plan?

o Examples include waiting too long on the phone,

in the waiting room, when getting a prescription,

or in the exam room.

Cleanliness • Are you unhappy with the cleanliness or condition of

a clinic, hospital, or doctor’s office?

Information you get from us • Do you believe we have not given you a notice that

we are required to give?

• Do you think written information we have given you

is hard to understand?

Timeliness

(These types of complaints are all

related to the timeliness of our

actions related to coverage

decisions and appeals)

The process of asking for a coverage decision and making

appeals is explained in sections 4-10 of this chapter. If

you are asking for a decision or making an appeal, you

use that process, not the complaint process.

However, if you have already asked us for a coverage

decision or made an appeal, and you think that we are not

responding quickly enough, you can also make a

complaint about our slowness. Here are examples:

• If you have asked us to give you a “fast coverage decision” or a “fast appeal,” and we have said we will

not, you can make a complaint.

• If you believe we are not meeting the deadlines for

giving you a coverage decision or an answer to an

appeal you have made, you can make a complaint.

• When a coverage decision we made is reviewed and

we are told that we must cover or reimburse you for

certain medical services or drugs, there are deadlines

that apply. If you think we are not meeting these

deadlines, you can make a complaint.

• When we do not give you a decision on time, we are

required to forward your case to the Independent

Review Organization. If we do not do that within the

required deadline, you can make a complaint.



Section 11.2 The formal name for “making a complaint” is “filing a grievance”

Legal Terms

•

•

•

What this section calls a “complaint”

is also called a “grievance.”

Another term for “making a

complaint” is “filing a grievance.”

Another way to say “using the process

for complaints” is “using the process

for filing a grievance.”

Section 11.3 Step-by-step: Making a complaint

Step 1: Contact us promptly – either by phone or in writing.

• Usually, calling Member Services is the first step. If there is anything else you need to

do, Member Services will let you know. Contact Member Services at 1-866-986-0356

(TTY: 711), 24 hours a day, 7 days a week.

• If you do not wish to call (or you called and were not satisfied), you can put your

complaint in writing and send it to us. If you put your complaint in writing, we will

respond to your complaint in writing.

o Send your written complaint to:



New York, NY 10038.

Attention: Complaints Manager

o You can file this complaint yourself, or have an authorized representative file the

complaint for you. To appoint an authorized representative, submit the

“Appointment of Representative Form,” located on our website at


o We will respond to your request in writing within 30 days. We may take another

14 days if you ask us to or if we require additional time to answer.

• Whether you call or write, you should contact Member Services right away. The

complaint must be made within 60 calendar days after you had the problem you want to

complain about.

• If you are making a complaint because we denied your request for a “fast coverage decision” or a “fast appeal,” we will automatically give you a “fast” complaint. If

you have a “fast” complaint, it means we will give you an answer within 24 hours.




Legal Terms

What this section calls a “fast complaint”

is also called an “expedited grievance.”

Step 2: We look into your complaint and give you our answer.

• If possible, we will answer you right away. If you call us with a complaint, we may be

able to give you an answer on the same phone call. If your health condition requires us to

answer quickly, we will do that.

• Most complaints are answered in 30 calendar days. If we need more information and

the delay is in your best interest or if you ask for more time, we can take up to 14 more

calendar days (44 calendar days total) to answer your complaint. If we decide to take

extra days, we will tell you in writing.

• If we do not agree with some or all of your complaint or don’t take responsibility for the problem you are complaining about, we will let you know. Our response will include our

reasons for this answer. We must respond whether we agree with the complaint or not.

Section 11.4 You can also make complaints about quality of care to the Quality Improvement Organization

You can make your complaint about the quality of care you received to us by using the step-by-

step process outlined above.

When your complaint is about quality of care, you also have two extra options:

• You can make your complaint to the Quality Improvement Organization. If you

prefer, you can make your complaint about the quality of care you received directly to

this organization (without making the complaint to us).

o The Quality Improvement Organization is a group of practicing doctors and other

health care experts paid by the Federal government to check and improve the care

given to Medicare patients.

o To find the name, address, and phone number of the Quality Improvement

Organization for your state, look in Chapter 2, Section 4 of this booklet. If you

make a complaint to this organization, we will work with them to resolve your

complaint.

• Or you can make your complaint to both at the same time. If you wish, you can make

your complaint about quality of care to us and also to the Quality Improvement

Organization.

Section 11.5 You can also tell Medicare about your complaint

You can submit a complaint about MetroPlus Advantage Plan (HMO SNP) directly to Medicare.

To submit a complaint to Medicare, go to



https://www.medicare.gov/MedicareComplaintForm/home.aspx. Medicare takes your complaints

seriously and will use this information to help improve the quality of the Medicare program.

If you have any other feedback or concerns, or if you feel the plan is not addressing your issue,

please call 1-800-MEDICARE (1-800-633-4227). TTY/TDD users can call 1-877-486-2048.

PROBLEMS ABOUT YOUR MEDICAID BENEFITS

SECTION 12 Handling problems about your Medicaid benefits

Consumers have a right to an external appeal when their HMO or insurer (health plan) denies

health care services as not medically necessary (including appropriateness, health care

setting, level of care, or effectiveness of a covered benefit), experimental / investigational

(including a clinical trial or rare disease treatment) or, in certain cases, out-of-network. To

request an external appeal, consumers or their designees must complete the attached application

and send it to the New York State Department of Financial Services within 4 months of the date

of the health plan's final adverse determination. Providers have their own right to an external

appeal when health care services are denied concurrently or retrospectively and must request an

external appeal within 60 days.

What Is An External Appeal? It is a request you make to the Department of Financial Services

when a health plan denies health care services. Your appeal will be reviewed by an independent

external appeal agent with medical experts that will either overturn (in whole or part), or uphold

the health plan's denial.

When Do I Request An External Appeal? You must first appeal the denial with your plan, or

you and your plan must agree to waive the internal appeal process. Applications for an external

appeal must be filed within 45 days of the plan’s final adverse determination from the first level

of appeal or from receipt of the plan’s letter waiving the internal appeal process. Providers

appealing on their own behalf must request an external appeal within 60 days of the final adverse

determination. If you do not send your application to the Department of Financial Services

within the required timeframe (with an additional 8 days allowed for mailing), you will not be

eligible for an external appeal. For more information, please contact the New York State

Department of Financial Services or by calling 1-800-400-8882.

What If Services Are Denied As Experimental / Investigational (including a Clinical Trial

or Rare Disease)? The patient's physician (for rare diseases cannot be the treating physician)

must complete and send pages 4-6 of the application to the Department of Financial Services.

What If Services Are Denied As Out-Of-Network? The patient must have an HMO or

managed care insurance contract and a pre-authorization request must be denied because the

service is not available in-network and the health plan recommends an alternate in-network

service that it believes is not materially different from the out-of- network service. The patient's

physician must complete and send pages 4-7 of the application to the Department of Financial

Services.




When Will An External Appeal Agent Make A Decision? Within 72 hours for expedited

appeals or 30 days for standard appeals. The external appeal agent's decision is binding on the

patient and the patient's health plan.

How Do I Request An Expedited (fast-tracked) External Appeal? The denial must concern

an admission, availability of care, continued stay, or health care service for which the patient

received emergency services and remains hospitalized; or the patient's physician must complete

pages 4-6 of the application and attest that the patient has not received the treatment and a 30 day

timeframe would seriously jeopardize the patient's life, health, or ability to regain maximum

function, or a delay will pose an imminent or serious threat to the patient's health. The patient

may request an expedited internal and external appeal at the same time. Once an external appeal

is expedited, a decision will be made in 72 hours, even if all the patient's medical information has

not been submitted.

When Can I Send Information To The External Appeal Agent? You will be notified when an

external appeal agent is assigned. You must send any information to the agent immediately.

Once the agent makes a decision, additional information will not be considered.

Do I Pay A Fee For An External Appeal? Health plans may charge a $25.00 fee to patients or

their designees, not to exceed $75.00 in a single plan year. The fee is waived for patients who

appeal and are covered under Medicaid, HIV SNP or HARP, or if the fee will pose a hardship.

Health plans may charge providers a $50.00 fee per appeal. The fee will be returned to you if the

external appeal agent overturns the health plan's denial.

What If A Patient Has Medicare Or Medicaid Coverage? Patients covered under Medicare

are not eligible for a NYS external appeal and should call 1-800-MEDICARE or visit

www.medicare.gov. Patients covered under regular Medicaid are not eligible for an external

appeal; however, patients covered under a Medicaid Managed Care Plan are eligible. All

Medicaid patients may also request a fair hearing, and the fair hearing decision will be the one

that applies. Call 1-800-342-3334 or visit www.otda.state.ny.us/oah for fair hearing information.

FOR QUESTIONS OR HELP WITH AN APPLICATION

CALL THE NEW YORK STATE DEPARTMENT OF FINANCIAL SERVICES AT 1-

800-400-8882,

E-MAIL US at [email protected] OR VISIT OUR WEBSITE at

www.dfs.ny.gov

If you are faxing an expedited appeal, call 1-888 990-3991.

To access the New York State External Appeal Application online, visit:

https://www.dfs.ny.gov/insurance/extapp/extappl.pdf

For instructions, visit: https://www.dfs.ny.gov/insurance/extapp/extappqa.htm

https://www.dfs.ny.gov/insurance/extapp/extappqa.htm

https://www.dfs.ny.gov/insurance/extapp/extappl.pdf

www.dfs.ny.gov

mailto:[email protected]

www.otda.state.ny.us/oah

www.medicare.gov



CHAPTER 10

Ending your membership in the plan


Chapter 10. Ending your membership in the plan



Section 1.1 This chapter focuses on ending your membership in our plan.................... 220

SECTION 2 When can you end your membership in our plan? ..................... 220

Section 2.1 You may be able to end your membership because you have Medicare

and Medicaid ............................................................................................... 220

Section 2.2 You can end your membership during the Annual Enrollment Period ....... 221

Section 2.3 You can end your membership during the Medicare Advantage Open

Enrollment Period........................................................................................ 222

Section 2.5 Where can you get more information about when you can end your

membership? ............................................................................................... 223

SECTION 3 How do you end your membership in our plan? ......................... 224

Section 3.1 Usually, you end your membership by enrolling in another plan ............... 224

SECTION 4 Until your membership ends, you must keep getting your medical services and drugs through our plan............................. 225

Section 4.1 Until your membership ends, you are still a member of our plan ............... 225

SECTION 5 MetroPlus Advantage Plan (HMO SNP) must end your membership in the plan in certain situations .............................. 226

Section 5.1 When must we end your membership in the plan? ..................................... 226

Section 5.2 We cannot ask you to leave our plan for any reason related to your health 227

Section 5.3 You have the right to make a complaint if we end your membership in

our plan........................................................................................................ 227




Section 1.1 This chapter focuses on ending your membership in our plan

Ending your membership in MetroPlus Advantage Plan (HMO SNP) may be voluntary (your

own choice) or involuntary (not your own choice):

• You might leave our plan because you have decided that you want to leave.

o There are only certain times during the year, or certain situations, when you may

voluntarily end your membership in the plan. Section 2 tells you when you can

end your membership in the plan. Section 2 tells you about the types of plans you

can enroll in and when your enrollment in your new coverage will begin.

o The process for voluntarily ending your membership varies depending on what

type of new coverage you are choosing. Section 3 tells you how to end your

membership in each situation.

• There are also limited situations where you do not choose to leave, but we are required to

end your membership. Section 5 tells you about situations when we must end your

membership.

If you are leaving our plan, you must continue to get your medical care through our plan until

your membership ends.

SECTION 2 When can you end your membership in our plan?

You may end your membership in our plan only during certain times of the year, known as

enrollment periods. All members have the opportunity to leave the plan during the Annual

Enrollment Period and during the Medicare Advantage Open Enrollment Period. In certain

situations, you may also be eligible to leave the plan at other times of the year.

Section 2.1 You may be able to end your membership because you have Medicare and Medicaid

Most people with Medicare can end their membership only during certain times of the year.

Because you have Medicaid, you may be able to end your membership in our plan or switch to a

different plan one time during each of the following Special Enrollment Periods:

• January to March

• April to June

• July to September

If you joined our plan during one of these periods, you’ll have to wait for the next period to end

your membership or switch to a different plan. You can’t use this Special Enrollment Period to

end your membership in our plan between October and December. However, all people with



Medicare can make changes from October 15 – December 7 during the Annual Enrollment

Period. Section 2.2 tells you more about the Annual Enrollment Period.

• What type of plan can you switch to? If you decide to change to a new plan, you can

choose any of the following types of Medicare plans:

o Another Medicare health plan. (You can choose a plan that covers prescription

drugs or one that does not cover prescription drugs.)

o Original Medicare with a separate Medicare prescription drug plan

▪ If you switch to Original Medicare and do not enroll in a separate

Medicare prescription drug plan, Medicare may enroll you in a drug plan,

unless you have opted out of automatic enrollment.

Note: If you disenroll from Medicare prescription drug coverage and go without

“creditable” prescription drug coverage for a continuous period of 63 days or more,

you may have to pay a Part D late enrollment penalty if you join a Medicare drug

plan later. (“Creditable” coverage means the coverage is expected to pay, on average,

at least as much as Medicare’s standard prescription drug coverage.)

Contact your State Medicaid Office to learn about your Medicaid plan options

(telephone numbers are in Chapter 2, Section 6 of this booklet).

• When will your membership end? Your membership will usually end on the first day of

the month after we receive your request to change your plans. Your enrollment in your

new plan will also begin on this day.

Section 2.2 You can end your membership during the Annual Enrollment Period

You can end your membership during the Annual Enrollment Period (also known as the “Annual

Open Enrollment Period”). This is the time when you should review your health and drug

coverage and make a decision about your coverage for the upcoming year.

• When is the Annual Enrollment Period? This happens from October 15 to

December 7.

• What type of plan can you switch to during the Annual Enrollment Period? You

can choose to keep your current coverage or make changes to your coverage for the

upcoming year. If you decide to change to a new plan, you can choose any of the

following types of plans:




o or – Original Medicare without a separate Medicare prescription drug plan.

If you receive “Extra Help” from Medicare to pay for your prescription drugs: If you switch to Original Medicare and do not enroll in a separate






creditable prescription drug coverage, you may have to pay a Part D late

enrollment penalty if you join a Medicare drug plan later. (“Creditable” coverage means the coverage is expected to pay, on average, at least as much as Medicare’s

standard prescription drug coverage.) See Chapter 1, Section 5 for more

information about the late enrollment penalty.

• When will your membership end? Your membership will end when your new

plan’s coverage begins on January 1.

Section 2.3 You can end your membership during the Medicare Advantage Open Enrollment Period

You have the opportunity to make one change to your health coverage during the Medicare

Advantage Open Enrollment Period.

• When is the annual Medicare Advantage Open Enrollment Period? This happens

every year from January 1 to March 31.

• What type of plan can you switch to during the annual Medicare Advantage

Open Enrollment Period? During this time, you can:

o Switch to another Medicare Advantage Plan. (You can choose a plan that covers

prescription drugs or one that does not cover prescription drugs.)

o Disenroll from our plan and obtain coverage through Original Medicare. If you

choose to switch to Original Medicare during this period, you have until March 31

to join a separate Medicare prescription drug plan to add drug coverage.

• When will your membership end? Your membership will end on the first day of the

month after you enroll in a different Medicare Advantage plan or we get your request to

switch to Original Medicare. If you also choose to enroll in a Medicare prescription drug

plan, your membership in the drug plan will begin the first day of the month after the

drug plan gets your enrollment request.

Section 2.4 In certain situations, you can end your membership during a Special Enrollment Period

In certain situations, you may be eligible to end your membership at other times of the year. This

is known as a Special Enrollment Period.

• Who is eligible for a Special Enrollment Period? If any of the following situations

apply to you, you may be eligible to end your membership during a Special

Enrollment Period. These are just examples, for the full list you can contact the plan,

call Medicare, or visit the Medicare website (https://www.medicare.gov):

o Usually, when you have moved

o If you have Medicaid

o If you are eligible for “Extra Help” with paying for your Medicare

prescriptions




o If we violate our contract with you

o If you are getting care in an institution, such as a nursing home or long-term

care (LTC) hospital

Note: Section 2.2 tells you more about the special enrollment period for people with

Medicaid.

• When are Special Enrollment Periods? The enrollment periods vary depending on

your situation.

• What can you do? To find out if you are eligible for a Special Enrollment Period,

please call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days

a week. TTY users call 1-877-486-2048. If you are eligible to end your membership

because of a special situation, you can choose to change both your Medicare health

coverage and prescription drug coverage. This means you can choose any of the

following types of plans:




o – or – Original Medicare without a separate Medicare prescription drug plan.

If you receive “Extra Help” from Medicare to pay for your prescription drugs: If you switch to Original Medicare and do not enroll in a separate




creditable prescription drug coverage for a continuous period of 63 days or more,

you may have to pay a Part D late enrollment penalty if you join a Medicare drug

plan later. (“Creditable” coverage means the coverage is expected to pay, on

average, at least as much as Medicare’s standard prescription drug coverage.) See

Chapter 1, Section 5 for more information about the late enrollment penalty.

• When will your membership end? Your membership will usually end on the first

day of the month after your request to change your plan is received.

Note: Sections 2.1 and 2.2 tell you more about the special enrollment period for people

with Medicaid and Extra Help.

Section 2.5 Where can you get more information about when you can end your membership?

If you have any questions or would like more information on when you can end your

membership:


booklet).

• You can find the information in the Medicare & You 2019 Handbook.



o Everyone with Medicare receives a copy of Medicare & You each fall. Those new

to Medicare receive it within a month after first signing up.

o You can also download a copy from the Medicare website

(https://www.medicare.gov). Or, you can order a printed copy by calling

Medicare at the number below.

• You can contact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day,

7 days a week. TTY users should call 1-877-486-2048.

SECTION 3 How do you end your membership in our plan?

Section 3.1 Usually, you end your membership by enrolling in another plan

Usually, to end your membership in our plan, you simply enroll in another Medicare plan.

However, if you want to switch from our plan to Original Medicare but you have not selected a

separate Medicare prescription drug plan, you must ask to be disenrolled from our plan. There

are two ways you can ask to be disenrolled:

• You can make a request in writing to us. Contact Member Services if you need more

information on how to do this (phone numbers are printed on the back cover of this

booklet).

• --or--You can contact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day,

7 days a week. TTY users should call 1-877-486-2048.

The table below explains how you should end your membership in our plan.

If you would like to switch from our

plan to:

• Another Medicare health plan

This is what you should do:

• Enroll in the new Medicare health plan. Your

new coverage will begin on the first day of

the following month.

You will automatically be disenrolled from

MetroPlus Advantage Plan (HMO SNP)

when your new plan’s coverage begins.

• Original Medicare with a separate

Medicare prescription drug plan

• Enroll in the new Medicare prescription drug

plan. Your new coverage will begin on the

first day of the following month.

You will automatically be disenrolled from

MetroPlus Advantage Plan (HMO SNP)

when your new plan’s coverage begins.




If you would like to switch from our

plan to: This is what you should do:

• Original Medicare without a separate • Send us a written request to disenroll.

Medicare prescription drug plan Contact Member Services if you need more

o If you switch to Original Medicare information on how to do this (phone

and do not enroll in a separate numbers are printed on the back cover of this

Medicare prescription drug plan, booklet).

Medicare may enroll you in a drug • You can also contact Medicare, at 1-800-plan, unless you have opted out of MEDICARE (1-800-633-4227), 24 hours a automatic enrollment. day, 7 days a week, and ask to be disenrolled.

o If you disenroll from Medicare TTY users should call 1-877-486-2048. prescription drug coverage and go • You will be disenrolled from MetroPlus without creditable prescription Advantage Plan (HMO SNP) when your drug coverage, you may have to coverage in Original Medicare begins. pay a late enrollment penalty if

you join a Medicare drug plan

later.

For questions about your Medicaid benefits, contact Human Resources Administration at 718-

557-1399. Ask how joining another plan or returning to Original Medicare affects how you get

your Medicaid coverage.

SECTION 4 Until your membership ends, you must keep getting your medical services and drugs through our plan

Section 4.1 Until your membership ends, you are still a member of our plan

If you leave MetroPlus Advantage Plan (HMO SNP), it may take time before your membership

ends and your new Medicare and Medicaid coverage goes into effect. (See Section 2 for

information on when your new coverage begins.) During this time, you must continue to get your

medical care and prescription drugs through our plan.

• You should continue to use our network pharmacies to get your prescriptions filled

until your membership in our plan ends. Usually, your prescription drugs are only

covered if they are filled at a network pharmacy including through our mail-order

pharmacy services.

• If you are hospitalized on the day that your membership ends, your hospital stay

will usually be covered by our plan until you are discharged (even if you are

discharged after your new health coverage begins).



SECTION 5 MetroPlus Advantage Plan (HMO SNP) must end your membership in the plan in certain situations

Section 5.1 When must we end your membership in the plan?

MetroPlus Advantage Plan (HMO SNP) must end your membership in the plan if any of

the following happen:

• If you no longer have Medicare Part A and Part B

• If you are no longer eligible for Medicaid. As stated in Chapter 1, Section 2.1, our plan is

for people who are eligible for both Medicare and Medicaid. If you lose your Medicaid

eligibility, you will no longer qualify for MetroPlus Advantage Plan (HMO SNP) and

will be disenrolled

• If you do not pay your medical spenddown, if applicable

• If you move out of our service area

• If you are away from our service area for more than six months

o If you move or take a long trip, you need to call Member Services to find out if

the place you are moving or traveling to is in our plan’s area. (Phone numbers for

Member Services are printed on the back cover of this booklet.)

• If you become incarcerated (go to prison)

• If you are not a United States citizen or lawfully present in the United States

• If you lie about or withhold information about other insurance you have that provides

prescription drug coverage

• If you intentionally give us incorrect information when you are enrolling in our plan and

that information affects your eligibility for our plan. (We cannot make you leave our plan

for this reason unless we get permission from Medicare first.)

• If you continuously behave in a way that is disruptive and makes it difficult for us to

provide medical care for you and other members of our plan. (We cannot make you leave

our plan for this reason unless we get permission from Medicare first.)

• If you let someone else use your membership card to get medical care. (We cannot make

you leave our plan for this reason unless we get permission from Medicare first.)

o If we end your membership because of this reason, Medicare may have your case

investigated by the Inspector General.

• If you do not pay the plan premiums for 90 days

o We must notify you in writing that you have 90 days to pay the plan premium

before we end your membership.

• If you are required to pay the extra Part D amount because of your income and you do not

pay it, Medicare will disenroll you from our plan



Where can you get more information?

If you have questions or would like more information on when we can end your membership:

• You can call Member Services for more information (phone numbers are printed on the

back cover of this booklet).

Section 5.2 We cannot ask you to leave our plan for any reason related to your health

MetroPlus Advantage Plan (HMO SNP) is not allowed to ask you to leave our plan for any

reason related to your health.

What should you do if this happens?

If you feel that you are being asked to leave our plan because of a health-related reason, you

should call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-

486-2048. You may call 24 hours a day, 7 days a week.

Section 5.3 You have the right to make a complaint if we end your membership in our plan

If we end your membership in our plan, we must tell you our reasons in writing for ending your

membership. We must also explain how you can file a grievance or make a complaint about our

decision to end your membership. You can also look in Chapter 9, Section 11 for information

about how to make a complaint.

CHAPTER 11

Legal notices


Chapter 11. Legal notices


SECTION 1 Notice about governing law........................................................... 230

SECTION 2 Notice about nondiscrimination.................................................... 230

SECTION 3 Notice about Medicare Secondary Payer subrogation rights..... 230



SECTION 1 Notice about governing law

Many laws apply to this Evidence of Coverage and some additional provisions may apply

because they are required by law. This may affect your rights and responsibilities even if the

laws are not included or explained in this document. The principal law that applies to this

document is Title XVIII of the Social Security Act and the regulations created under the Social

Security Act by the Centers for Medicare & Medicaid Services, or CMS. In addition, other

Federal laws may apply and, under certain circumstances, the laws of the state you live in.

SECTION 2 Notice about nondiscrimination

We don’t discriminate based on race, ethnicity, national origin, color, religion, sex, gender, age,

mental or physical disability, health status, claims experience, medical history, genetic

information, evidence of insurability, or geographic location. All organizations that provide

Medicare Advantage plans, like our plan, must obey Federal laws against discrimination,

including Title VI of the Civil Rights Act of 1964, the Rehabilitation Act of 1973, the Age

Discrimination Act of 1975, the Americans with Disabilities Act, Section 1557 of the Affordable

Care Act, all other laws that apply to organizations that get Federal funding, and any other laws

and rules that apply for any other reason.

SECTION 3 Notice about Medicare Secondary Payer subrogation rights

We have the right and responsibility to collect for covered Medicare services for which Medicare

is not the primary payer. According to CMS regulations at 42 CFR sections 422.108 and

423.462, MetroPlus Advantage Plan (HMO SNP), as a Medicare Advantage Organization, will

exercise the same rights of recovery that the Secretary exercises under CMS regulations in

subparts B through D of part 411 of 42 CFR and the rules established in this section supersede

any State laws.

Effective July 10, 2017

MetroPlus Health Plan Annual Privacy Notice

MetroPlus respects your privacy rights. This notice describes how we treat the nonpublic

personal financial and health information (“Information”) we receive about you and what we

do to keep it confidential and secure as required by New York State Insurance Law (Regulation

169).

In addition, you can request a full text version of MetroPlus Health Plan’s Notice of Health Information Privacy Practices, which describes how medical information about you may be used and disclosed under the Federal Health Insurance Portability and Accountability Act (HIPAA) at any time by contacting the MetroPlus Privacy Officer. This information is also available on our website at www.metroplus.org/privacy-policies

MetroPlus collects • Information you give us on application and other forms or

Information about you that you tell us; and

from the following • Information about your dealings with us, the health care

sources and may providers we work with, and others.

disclose:

What we do with your

information: • To provide the health care benefits you receive as a member

of MetroPlus Health Plan, for example, to arrange for We do not disclose treatment that you need and to pay for services you receive; Information about our • To communicate with you about programs and services that members and former are available to you as a MetroPlus member; and members to anyone, • To manage our business and comply with legal and regulatory except as permitted by requirements. law.

MBR 17.105v2

http://www.metroplus.org/privacy-policies



How we protect your

privacy

• We limit access to your Information to employees and other

persons who need it to conduct MetroPlus business or comply

with legal and regulatory requirements.

• Employees are subject to discipline, and may be fired, if they

violate our privacy policies and procedures.

• We also use physical, electronic and procedural safeguards to

keep Information confidential and secure in accordance with

state and federal regulations.

Former Members • If your membership with MetroPlus ends, your Information

will remain protected in accordance with our policies and

procedures for current members.

Contact

MetroPlus

• Request more information about our privacy policies and

practices,

• File a privacy-related complaint with us, or

• Request (in writing) to review Information about you in our

records.

Customer Services – MetroPlus Health Plan


New York, NY 10038

General Phone: 1-800-303-9626, 7 days per week 8:00 a.m. to 8:00 p.m.

Medicare Members: 1-866-986-0356, 7 days per week, 8:00 a.m. to 8:00

p.m.

FIDA Members: 1-844-288-3432, 7 days per week, 8:00 a.m. to 8:00 p.m.

TTY: 711

E-mail: [email protected]




Effective July 1, 2018



New York, NY 10038

Website: www.metroplus.org Your Information. General Phone: 1-800-303-9626

TTY: 711 Your Rights. E-mail: [email protected]

Our Responsibilities.

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get a copy of your health and claims records

• You can ask to see or get a copy of your health and claims records and other health information we have about you. Ask us how to do this.

• We will provide a copy or a summary of your health and claims records, usually within 30 days of your request. We will charge you $0.75 (75 cents) for each page of copies you request.

Ask us to correct health • You can ask us to correct your health and claims records if you and claims records think they are incorrect or incomplete. Ask us how to do this.

• We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential • You can ask us to contact you in a specific way (for example, home communications or office phone) or to send mail to a different address.

• We will consider all reasonable requests, and must say “yes” if you tell us you would be in danger if we do not.

continued on next page

MBR 18.146

http://www.metroplus.org/




Ask us to limit what we • You can ask us not to use or share certain health information for

use or share treatment, payment, or our operations. • We are not required to agree to your request, and we may say “no”

if it would affect your care

Get a list of those with whom we’ve shared information

• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.

• We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

• To ask for confidential communications, call our Member Services Department at 1-800-303-9626 (TTY: 711). Requests to change or modify this type of confidential communication request must be made in writing to the address listed below.

Get a copy of this privacy • You can ask for a paper copy of this notice at any time, even if you notice have agreed to receive the notice electronically. We will provide you

with a paper copy promptly. You may get a paper copy of this notice at any time by calling our Member Services Department at 1-800-303-9626 (TTY: 711).

Choose someone to • If you have given someone medical power of attorney or if act for you someone is your legal guardian, that person can exercise your

rights and make choices about your health information. • We will make sure the person has this authority and can act for

you before we take any action.

File a complaint if you feel your rights are violated

• You can complain if you feel we have violated your rights by contacting us using the information on page 1.

• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.

• We will not retaliate against you for filing a complaint.

http://www.hhs.gov/ocr/privacy/hipaa/complaints/



For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have • Share information with your family, close friends, or others both the right and choice

involved in payment for your care. to tell us to:

How do we typically use or share your health information? We typically use or share your health information in the following ways.

Help manage the health care treatment you receive

• We can use your health information and share it with professionals who are treating you.

• Health Related Products or Programs: MetroPlus may provide you information

Example: A doctor sends us information about your diagnosis and treatment plan so we can arrange additional services.

on medical treatments, programs products and services. The information provided to you is subject to any limits imposed by the law

• Reminders: MetroPlus may use and disclose PHI about you (for example, by calling you or sending you a letter) to remind you of an appointment for treatment or that it’s time for you to schedule an appointment for a regular check-up or immunization, or to provide information about treatment alternatives (“choices”) or other health-related benefits and services that may be of interest to you.




Run our organization

• We can use and disclose your information to run our organization and contact you when necessary.

Example: We use health information about you to develop better services for you.

MetroPlus’ Quality Management Department may use your health information to help improve the quality of the Plan’s programs, data and business processes. As an example, your medical record may be reviewed by our quality management staff or contracted nurse reviewers to evaluate the quality of care provided to you and all Plan members.

Pay for your health services • We can use and disclose your health

information as we pay for your health services.

Example: We share information about you with your dental plan to coordinate payment for your dental work.

Administer your plan

• We may disclose your health information to your health plan sponsor for plan administration.




Help with public • We can share health information about you for certain situations health and safety such as: issues o Preventing disease

o Reporting suspected abuse, neglect, or domestic violence o Preventing or reducing a serious threat to anyone’s health

or safety

Comply with the • We will share information about you if state or federal laws require law it, including with the Department of Health and Human Services if it

wants to see that we’re complying with federal privacy law.

Address workers’ • We can use or share health information about you: compensation, law o For worker’s compensation claims enforcement, and o For law enforcement purposes or with a law enforcement other government official requests o With health oversight agencies authorized by law

o For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal action

• We can share health information about you in response to a court or legal administrative order, or in response to a subpoena

In these cases, we never share your information

• We never market or sell personal information

New York State • MetroPlus must comply with additional New York State laws that laws on disclosures have a higher level of protection for personal information, for certain types of particularly information relating to HIV/AIDS status or treatment; information mental health; substance use disorder; and family planning.



• We are required by law to maintain the privacy and security of your protected health information.

• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

• We must follow the duties and privacy practices described in this notice and give you a copy of it.

• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of This Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, on our web site, and we will mail a copy to you.

Privacy Officer Contact Information

If you have questions about our privacy practices, or if you want to file a complaint or exercise rights described above, please contact:

Customer Services – MetroPlus Health Plan 160 Water Street, 3rd Floor New York, NY 10038

General Phone: 1-800-303-9626, 7 days per week 8:00 a.m. to 8:00 p.m.

Medicare Members: 1-866-986-0356, 7 days per week, 8:00 a.m. to 8:00 p.m.

FIDA Members: 1-844-288-3432, 7 days per week, 8:00 a.m. to 8:00 p.m.

TTY: 711

E-mail: [email protected]

http://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html




Multi-Language Interpreter Services and Non-Discrimination

MetroPlus Health Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. MetroPlus Health Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

MetroPlus Health Plan:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as:

- Written information in other formats (large print, audio, accessible electronic formats, other formats) - TTY Services

• Provides free language services to people whose primary language is not English, such as: - Qualified interpreters - Information written in other languages

If you need these services, contact MetroPlus Member Services at 1-800-303-9626. We are happy to take your calls from Mon. - Sat., 8 am - 8 pm. After 8 pm, Sundays & Holidays: 24/7 Medical Answering Service at 1-800-442-2560. The call is free. For persons who have trouble hearing or speaking, please use our TTY number: 711

If you believe that MetroPlus Health Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:

MetroPlus Health Plan, Attn: Complaints Manager 160 Water Street, 3rd Floor

New York, NY 10038 Phone: 1-800-303-9626 • Fax: 1-212-908-5196

You can file a grievance by mail, or by fax. If you need help filing a grievance, the MetroPlus Health Plan Grievance Department is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

MBR 18.153

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf



U.S. Department of Health and Human Services 200 Independence Avenue SW., Room 509F, HHH Building,

Washington, DC 20201 1-800-368-1019, 800-537-7697 (TDD).

Complaint forms are available at http://www.hhs.gov/ocr/oce/-le/index.html.

Spanish: ATENCIÓN: Si usted habla español, tiene a su disposición servicios de asistencia con el idioma. Llame a Servicios al Miembro de MetroPlus al 1-800-303-9626. Con gusto responderemos sus llamadas de lunes a sábado, de 8 a. m. a 8 p. m. Después de las 8 p.m., los domingos y días festivos: Servicio de Recepción de Llamadas Médicas, las 24 horas, 7 días a la semana llamando al 1-800-442-2560. La llamada es gratuita.

Chinese: 收件人：如果您说普通话，我们可为您提供语言协助服务。请拨打 MetroPlus 会员服务部电话 1-800-303-9626。我们欢迎您在以下时间拨打电话：周一至周六，早 8 点至晚 8 点晚 8 点后、周日及节假日：每周 7 天、每天 24 小时：医疗问题应答服务： 1-800-442-2560。该电话免费。

Russian: ВНИМАНИЕ: Если вы говорите на России, вы можете воспользоваться помощью переводчика. Звоните в Службу поддержки участников MetroPlus по номеру 1-800-303-9626. Мы работаем с понедельника по субботу с 8 утра до 8 вечера. После 8 вечера по воскресеньям и праздничным дням: круглосуточно: Медицинская справочная служба по номеру 1-800-442-2560. Звонок бесплатный.

French Creole: ATANSYON: Si w pale kreyòl ayisyen, w ap jwenn sèvis asistans lang. Rele Sèvis Manm MetroPlus nan 1-800-303-9626. Nou kontan resevwa apèl ou soti lendi rive samdi, 8 am - 8 pm. Apre 8 pm, dimanch & jou ferye: 24/24: Sèvis Repondè Medikal nan 1-800-442-2560. Apèl la gratis.

Korean: 주의: 귀하가 한국어를 사용하는 경우, 귀하에게 언어 지원 서비스가 제공됩니다 .MetroPlus 가입자 서비스로 문의하십시오 . 1-800-303-9626. 통화 가능 시간은 월요일-토요일 오전8시-오후 8시입니다. 오후 8시 이후, 일요일과 휴일: 1-800-442-2560 번호로 24시간 의료 응답서비스가 제공됩니다. 통화는 무료입니다.

Italian: ATTENZIONE: Se Lei parla italiano, sono disponibili servizi di assistenza linguistica. Telefonare ai servizi per i membri al numero 1-800-303-9626. Siamo felici di rispondere alle vostre richieste da lunedì a sabato, dalle 8 alle 20. Dopo le 20, la domenica e i festivi: 24/7 segreteria telefonica medica al numero 1-800-442-2560 La telefonata è gratuita.

:Yiddish ןנעזע, שדייאטרעד ריאבויא: אםקזערפמיאו 1-800-303-9626. . יךאי ארפטיריג עסיסורוסע ףליה אךשפר

ןפור ערעייא ןנעמע צו ןידפרוצ ןזענע ירמ ףיוא ססעיווסער מעמבער MetroPlus פטור ןוא טאגונז, וונטא יגעריאז 8 נאך. ונטוא יגעריאז 8 ביז יפרדערינא יגעריאז 8 , בתשיזב טאגאנמ פון .אלפצא פון ייפר זיאףור דער .1-800-442-2560 ףיוא סיוורסע ינגנסערע שעייניצעדמ :24/7 : ותאחג

Polish: UWAGA: Jezeli mówisz po polsku, z mysla o Twoich potrzebach udostepnione zostały usługi w Twoim jezyku. Zadzwon do Punktu usług dla uczestników programu MetroPlus pod numer 1-800-303-9626. Czekamy na Twój telefon od poniedziałku do soboty w godzinach 8:00-

http://www.hhs.gov/ocr/oce/-le/index.html



20:00. Po godzinie 20:00, w niedziele i swieta: Punkt przyjmowania zgłoszen medycznych, dostepny 24/7 pod numerem telefonu 1-800-442-2560. Połaczenia telefoniczne sa bezpłatne.

:Arabic عضاءأتماخدبلصاتالا نككمي. ةلغويلا دةاعمسلا خدمات ىلع صولحلا مكنكفي ة،ربيلعا حدثتت تكن إذا: ظةحولم MetroPlus بت،الس لىإ نينثالا من تكمماالكم تلقي عدنايس .9626-303-800-1 مرقال لىع

فرتوت: يومو ًًءاسم 8 ىإل اًحابص 8 من

يومال تعاسا لوطوا عبوألسا اردم لىعةمخد: ًًءاسم 8 بعد تطالعال وأيام حدألا. 1-مرقال لىعةيبالط ةبتجاالساةمخد

.ًاناجم تماالكمال فرتوت .800-442-2560

French: ATTENTION : Si vous parlez français, un service d’assistance vous est proposé. Appelez le service membre de MétroPlus au 1-800-303-9626 Nous serons heureux de vous répondre du lundi au samedi, de 8 h à 20 h Après 20 h, les dimanche & jours fériés : 24 h / 24, 7 j / 7 Service répondeur téléphonique médical au 1-800-442-2560. L’appel est gratuit.

:Urdu ہیں۔ یابدست دماتخ کی مدد لقمتع سے انزب لیے کے آپ تو، ہیں لتےبو انزب دورا آپ، راگ: دیں اندھی MetroPlus یرپ بخوشی ںیالک کی آپ ہم ں۔یکر لکا پر 9626-303-800-1 کو سروسز برمم

لکیمیڈ:24/7 :–

اور بعد کے بجے 8 شام ں۔یہ تےکر لوصو تک بجے 8 شام تا 8 حبص ہ،تفہ

گننسرآ تیالعطت ورا ارتوا 442-800-1-وسسر ہے۔ مفت لکا ہے۔ بتیادس 2560

Tagalog: PAUNAWA: Kung nakapagsasalita kayo ng Tagalog, may magagamit kayong mga serbisyong tulong sa lengguwahe. Tawagan ang Mga Serbisyo sa Miyembro ng MetroPlus sa 1-800-303-9626. Nagagalak kaming sagutin ang mga tawag ninyo mula Lunes - Sabado, 8 am - 8 pm. Makalipas ang 8 pm, mga araw ng Linggo at Pista Opisyal: 24/7: Medikal na Serbisyong Pagsagot sa Telepono sa 1-800-442-2560. Libre ang tawag.

Greek: ΠΡΟΣΟΧΗ: Αν μιλάτε Ελληνικά, υπάρχουν στη διάθεσή σας υπηρεσίες βοήθειας στη γλώσσα σας. Αποταθείτε στις Υπηρεσίες για Μέλη της MetroPlus καλώντας τον αριθμό 1-800-303-9626. Είμαστε στη διάθεσή σας για να απαντήσουμε στις κλήσεις σας από Δευτέρα έως Σάββατο, 8 π.μ. - 8 μ.μ. Καθημερινές μετά τις 8 μ.μ., Κυριακές & αργίες: Όλο το 24ωρο επί 7 ημέρες την εβδομάδα: Υπηρεσία Απαντήσεων για Ιατρικά Θέματα, 1-800-442-2560. Η κλήση σας δεν χρεώνεται.

Albanian: VINI RE: Nëse £isni shqip, shërbimet e ndihmës së gjuhës janë në dispozicionin tuaj. Telefononi Shërbimet e Anëtarit të MetroPlus në 1-800-303-9626. Jemi të gëzuar t’u përgjigjemi telefonatave tuaja nga e hëna – të shtunën, 8 paradite - 8 pasdite. Pas 8 pasdite, të dielave dhe festave: në çdo orë të çdo dite: Shërbimi i Përgjigjeve Mjekësore në 1-800-442-2560. Telefonata është falas.

CHAPTER 12

Definitions of important words


Chapter 12. Definitions of important words


Ambulatory Surgical Center – An Ambulatory Surgical Center is an entity that operates

exclusively for the purpose of furnishing outpatient surgical services to patients not requiring

hospitalization and whose expected stay in the center does not exceed 24 hours.

Appeal – An appeal is something you do if you disagree with our decision to deny a request for

coverage of health care services or prescription drugs or payment for services or drugs you

already received. You may also make an appeal if you disagree with our decision to stop services

that you are receiving. For example, you may ask for an appeal if we don’t pay for a drug, item,

or service you think you should be able to receive. Chapter 9 explains appeals, including the

process involved in making an appeal.

Balance Billing – When a provider (such as a doctor or hospital) bills a patient more than the

plan’s allowed cost-sharing amount. As a member of MetroPlus Advantage Plan (HMO SNP),

you only have to pay our plan’s cost-sharing amounts when you get services covered by our

plan. We do not allow providers to “balance bill” or otherwise charge you more than the amount of cost-sharing your plan says you must pay.

Benefit Period – The way that both our plan and Original Medicare measures your use of

hospital and skilled nursing facility (SNF) services. A benefit period begins the day you go into a

hospital or skilled nursing facility. The benefit period ends when you haven’t received any inpatient hospital care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or

a skilled nursing facility after one benefit period has ended, a new benefit period begins. There is

no limit to the number of benefit periods.

Brand Name Drug – A prescription drug that is manufactured and sold by the pharmaceutical

company that originally researched and developed the drug. Brand name drugs have the same

active-ingredient formula as the generic version of the drug. However, generic drugs are

manufactured and sold by other drug manufacturers and are generally not available until after the

patent on the brand name drug has expired.

Catastrophic Coverage Stage – The stage in the Part D Drug Benefit where you pay a low

copayment or coinsurance for your drugs after you or other qualified parties on your behalf have

spent $5,100 in covered drugs during the covered year.

Centers for Medicare & Medicaid Services (CMS) – The Federal agency that administers

Medicare. Chapter 2 explains how to contact CMS.

Coinsurance – An amount you may be required to pay as your share of the cost for services or

prescription drugs after you pay any deductibles. Coinsurance is usually a percentage (for

example, 20%).

Complaint — The formal name for “making a complaint” is “filing a grievance.” The complaint

process is used for certain types of problems only. This includes problems related to quality of

care, waiting times, and the customer service you receive. See also “Grievance,” in this list of

definitions.



Comprehensive Outpatient Rehabilitation Facility (CORF) – A facility that mainly provides

rehabilitation services after an illness or injury, and provides a variety of services including

physical therapy, social or psychological services, respiratory therapy, occupational therapy and

speech-language pathology services, and home environment evaluation services.

Copayment (or “copay”) – An amount you may be required to pay as your share of the cost for

a medical service or supply, like a doctor’s visit, hospital outpatient visit, or a prescription drug.

A copayment is a set amount, rather than a percentage. For example, you might pay $10 or $20

for a doctor’s visit or prescription drug.

Cost-sharing – Cost-sharing refers to amounts that a member has to pay when services or drugs

are received. (This is in addition to the plan’s monthly premium.) Cost-sharing includes any

combination of the following three types of payments: (1) any deductible amount a plan may

impose before services or drugs are covered; (2) any fixed “copayment” amount that a plan

requires when a specific service or drug is received; or (3) any “coinsurance” amount, a percentage of the total amount paid for a service or drug that a plan requires when a specific

service or drug is received. A “daily cost-sharing rate” may apply when your doctor prescribes

less than a full month’s supply of certain drugs for you and you are required to pay a copayment.

Cost-Sharing Tier – Every drug on the list of covered drugs is in one of two cost-sharing tiers.

In general, the higher the cost-sharing tier, the higher your cost for the drug.

Coverage Determination – A decision about whether a drug prescribed for you is covered by

the plan and the amount, if any, you are required to pay for the prescription. In general, if you

bring your prescription to a pharmacy and the pharmacy tells you the prescription isn’t covered

under your plan, that isn’t a coverage determination. You need to call or write to your plan to ask

for a formal decision about the coverage. Coverage determinations are called “coverage decisions” in this booklet. Chapter 9 explains how to ask us for a coverage decision.

Covered Drugs – The term we use to mean all of the prescription drugs covered by our plan.

Covered Services – The general term we use to mean all of the health care services and supplies

that are covered by our plan.

Creditable Prescription Drug Coverage – Prescription drug coverage (for example, from an

employer or union) that is expected to pay, on average, at least as much as Medicare’s standard

prescription drug coverage. People who have this kind of coverage when they become eligible

for Medicare can generally keep that coverage without paying a penalty, if they decide to enroll

in Medicare prescription drug coverage later.

Custodial Care – Custodial care is personal care provided in a nursing home, hospice, or other

facility setting when you do not need skilled medical care or skilled nursing care. Custodial care

is personal care that can be provided by people who don’t have professional skills or training,

such as help with activities of daily living like bathing, dressing, eating, getting in or out of a bed

or chair, moving around, and using the bathroom. It may also include the kind of health-related

care that most people do themselves, like using eye drops. Medicare doesn’t pay for custodial

care.



Daily cost-sharing rate – A “daily cost-sharing rate” may apply when your doctor prescribes

less than a full month’s supply of certain drugs for you and you are required to pay a copayment.

A daily cost-sharing rate is the copayment divided by the number of days in a month’s supply.

Here is an example: If your copayment for a one-month supply of a drug is $30, and a one-

month’s supply in your plan is 30 days, then your “daily cost-sharing rate” is $1 per day. This

means you pay $1 for each day’s supply when you fill your prescription.

Deductible – The amount you must pay for health care or prescriptions before our plan begins to

pay.

Disenroll or Disenrollment – The process of ending your membership in our plan.

Disenrollment may be voluntary (your own choice) or involuntary (not your own choice).

Dispensing Fee – A fee charged each time a covered drug is dispensed to pay for the cost of

filling a prescription. The dispensing fee covers costs such as the pharmacist’s time to prepare and package the prescription.

Dual Eligible Individual – A person who qualifies for Medicare and Medicaid coverage.

Durable Medical Equipment (DME) – Certain medical equipment that is ordered by your

doctor for medical reasons. Examples include walkers, wheelchairs, crutches, powered mattress

systems, diabetic supplies, IV infusion pumps, speech generating devices, oxygen equipment,

nebulizers, or hospital beds ordered by a provider for use in the home.

Emergency – A medical emergency is when you, or any other prudent layperson with an

average knowledge of health and medicine, believe that you have medical symptoms that require

immediate medical attention to prevent loss of life, loss of a limb, or loss of function of a limb.

The medical symptoms may be an illness, injury, severe pain, or a medical condition that is

quickly getting worse.

Emergency Care – Covered services that are: (1) rendered by a provider qualified to furnish

emergency services; and (2) needed to treat, evaluate, or stabilize an emergency medical

condition.

Evidence of Coverage (EOC) and Disclosure Information – This document, along with your

enrollment form and any other attachments, riders, or other optional coverage selected, which

explains your coverage, what we must do, your rights, and what you have to do as a member of

our plan.

Exception – A type of coverage determination that, if approved, allows you to get a drug that is

not on your plan sponsor’s formulary (a formulary exception), or get a non-preferred drug at a

lower cost-sharing level (a tiering exception). You may also request an exception if your plan

sponsor requires you to try another drug before receiving the drug you are requesting, or the plan

limits the quantity or dosage of the drug you are requesting (a formulary exception).

Extra Help – A Medicare program to help people with limited income and resources pay

Medicare prescription drug program costs, such as premiums, deductibles, and coinsurance.



Generic Drug – A prescription drug that is approved by the Food and Drug Administration

(FDA) as having the same active ingredient(s) as the brand name drug. Generally, a “generic” drug works the same as a brand name drug and usually costs less.

Grievance – A type of complaint you make about us or pharmacies, including a complaint

concerning the quality of your care. This type of complaint does not involve coverage or

payment disputes.

Home Health Aide – A home health aide provides services that don’t need the skills of a licensed nurse or therapist, such as help with personal care (e.g., bathing, using the toilet,

dressing, or carrying out the prescribed exercises). Home health aides do not have a nursing

license or provide therapy.

Hospice – A member who has 6 months or less to live has the right to elect hospice. We, your

plan, must provide you with a list of hospices in your geographic area. If you elect hospice and

continue to pay premiums you are still a member of our plan. You can still obtain all medically

necessary services as well as the supplemental benefits we offer. The hospice will provide

special treatment for your state.

Hospital Inpatient Stay – A hospital stay when you have been formally admitted to the hospital

for skilled medical services. Even if you stay in the hospital overnight, you might still be

considered an “outpatient.”

Income Related Monthly Adjustment Amount (IRMAA) – If your income is above a certain

limit, you will pay an income-related monthly adjustment amount in addition to your plan

premium. For example, individuals with income greater than $85,000 and married couples with

income greater than $170,000 must pay a higher Medicare Part B (medical insurance) and

Medicare prescription drug coverage premium amount. This additional amount is called the

income-related monthly adjustment amount. Less than 5% of people with Medicare are affected,

so most people will not pay a higher premium.

Initial Coverage Limit – The maximum limit of coverage under the Initial Coverage Stage.

Initial Coverage Stage – This is the stage before your: total drug costs including amounts you

have paid and what your plan has paid on your behalf for the year have reached $3,820.

Initial Enrollment Period – When you are first eligible for Medicare, the period of time when

you can sign up for Medicare Part A and Part B. For example, if you’re eligible for Medicare

when you turn 65, your Initial Enrollment Period is the 7-month period that begins 3 months

before the month you turn 65, includes the month you turn 65, and ends 3 months after the month

you turn 65.

Institutional Special Needs Plan (SNP) – A Special Needs Plan that enrolls eligible individuals

who continuously reside or are expected to continuously reside for 90 days or longer in a long-

term care (LTC) facility. These LTC facilities may include a skilled nursing facility (SNF);

nursing facility (NF); (SNF/NF); an intermediate care facility for the mentally retarded

(ICF/MR); and/or an inpatient psychiatric facility. An institutional Special Needs Plan to serve



Medicare residents of LTC facilities must have a contractual arrangement with (or own and

operate) the specific LTC facility(ies).

Institutional Equivalent Special Needs Plan (SNP) – An institutional Special Needs Plan that

enrolls eligible individuals living in the community but requiring an institutional level of care

based on the State assessment. The assessment must be performed using the same respective

State level of care assessment tool and administered by an entity other than the organization

offering the plan. This type of Special Needs Plan may restrict enrollment to individuals that

reside in a contracted assisted living facility (ALF) if necessary to ensure uniform delivery of

specialized care.

List of Covered Drugs (Formulary or “Drug List”) – A list of prescription drugs covered by

the plan. The drugs on this list are selected by the plan with the help of doctors and pharmacists.

The list includes both brand name and generic drugs.

Low Income Subsidy (LIS) – See “Extra Help.”

Maximum Out-of-Pocket Amount – The most that you pay out-of-pocket during the calendar

year for covered services. Amounts you pay for your plan premiums, Medicare Part A and Part B

premiums, and prescription drugs do not count toward the maximum out-of-pocket amount.

(Note: Because our members also get assistance from Medicaid, very few members ever reach

this out-of-pocket maximum.) See Chapter 4, Section 1.3 for information about your maximum

out-of-pocket amount.

Medicaid (or Medical Assistance) – A joint Federal and state program that helps with medical

costs for some people with low incomes and limited resources. Medicaid programs vary from

state to state, but most health care costs are covered if you qualify for both Medicare and

Medicaid. See Chapter 2, Section 6 for information about how to contact Medicaid in your state.

Medically Accepted Indication – A use of a drug that is either approved by the Food and Drug

Administration or supported by certain reference books. See Chapter 5, Section 3 for more

information about a medically accepted indication.

Medically Necessary – Services, supplies, or drugs that are needed for the prevention, diagnosis,

or treatment of your medical condition and meet accepted standards of medical practice.

Medicare – The Federal health insurance program for people 65 years of age or older, some

people under age 65 with certain disabilities, and people with End-Stage Renal Disease

(generally those with permanent kidney failure who need dialysis or a kidney transplant). People

with Medicare can get their Medicare health coverage through Original Medicare or a Medicare

Advantage Plan.

Medicare Advantage (MA) Plan – Sometimes called Medicare Part C. A plan offered by a

private company that contracts with Medicare to provide you with all your Medicare Part A and

Part B benefits. A Medicare Advantage Plan can be an HMO, PPO, a Private Fee-for-Service

(PFFS) plan, or a Medicare Medical Savings Account (MSA) plan. When you are enrolled in a

Medicare Advantage Plan, Medicare services are covered through the plan, and are not paid for



under Original Medicare. In most cases, Medicare Advantage Plans also offer Medicare Part D

(prescription drug coverage). These plans are called Medicare Advantage Plans with

Prescription Drug Coverage. Everyone who has Medicare Part A and Part B is eligible to join

any Medicare health plan that is offered in their area, except people with End-Stage Renal

Disease (unless certain exceptions apply).

Medicare Coverage Gap Discount Program – A program that provides discounts on most

covered Part D brand name drugs to Part D members who have reached the Coverage Gap Stage

and who are not already receiving “Extra Help.” Discounts are based on agreements between the

Federal government and certain drug manufacturers. For this reason, most, but not all, brand

name drugs are discounted.

Medicare-Covered Services – Services covered by Medicare Part A and Part B. All Medicare

health plans, including our plan, must cover all of the services that are covered by Medicare Part

A and B.

Medicare Health Plan – A Medicare health plan is offered by a private company that contracts

with Medicare to provide Part A and Part B benefits to people with Medicare who enroll in the

plan. This term includes all Medicare Advantage Plans, Medicare Cost Plans,

Demonstration/Pilot Programs, and Programs of All-inclusive Care for the Elderly (PACE).

Medicare Prescription Drug Coverage (Medicare Part D) – Insurance to help pay for

outpatient prescription drugs, vaccines, biologicals, and some supplies not covered by Medicare

Part A or Part B.

“Medigap” (Medicare Supplement Insurance) Policy – Medicare supplement insurance sold

by private insurance companies to fill “gaps” in Original Medicare. Medigap policies only work

with Original Medicare. (A Medicare Advantage Plan is not a Medigap policy.)

Member (Member of our Plan, or “Plan Member”) – A person with Medicare who is eligible

to get covered services, who has enrolled in our plan and whose enrollment has been confirmed

by the Centers for Medicare & Medicaid Services (CMS).

Member Services – A department within our plan responsible for answering your questions

about your membership, benefits, grievances, and appeals. See Chapter 2 for information about

how to contact Member Services.

Network Pharmacy – A network pharmacy is a pharmacy where members of our plan can get

their prescription drug benefits. We call them “network pharmacies” because they contract with

our plan. In most cases, your prescriptions are covered only if they are filled at one of our

network pharmacies.

Network Provider – “Provider” is the general term we use for doctors, other health care

professionals, hospitals, and other health care facilities that are licensed or certified by Medicare

and by the State to provide health care services. We call them “network providers” when they have an agreement with our plan to accept our payment as payment in full, and in some cases to

coordinate as well as provide covered services to members of our plan. Our plan pays network



providers based on the agreements it has with the providers or if the providers agree to provide

you with plan-covered services. Network providers may also be referred to as “plan providers.”

Organization Determination – The Medicare Advantage plan has made an organization

determination when it makes a decision about whether items or services are covered or how

much you have to pay for covered items or services. Organization determinations are called

“coverage decisions” in this booklet. Chapter 9 explains how to ask us for a coverage decision.

Original Medicare (“Traditional Medicare” or “Fee-for-service” Medicare) – Original Medicare

is offered by the government, and not a private health plan like Medicare Advantage Plans and

prescription drug plans. Under Original Medicare, Medicare services are covered by paying

doctors, hospitals, and other health care providers payment amounts established by Congress.

You can see any doctor, hospital, or other health care provider that accepts Medicare. You must

pay the deductible. Medicare pays its share of the Medicare-approved amount, and you pay your

share. Original Medicare has two parts: Part A (Hospital Insurance) and Part B (Medical

Insurance) and is available everywhere in the United States.

Out-of-Network Pharmacy – A pharmacy that doesn’t have a contract with our plan to

coordinate or provide covered drugs to members of our plan. As explained in this Evidence of

Coverage, most drugs you get from out-of-network pharmacies are not covered by our plan

unless certain conditions apply.

Out-of-Network Provider or Out-of-Network Facility – A provider or facility with which we

have not arranged to coordinate or provide covered services to members of our plan. Out-of-

network providers are providers that are not employed, owned, or operated by our plan or are not

under contract to deliver covered services to you. Using out-of-network providers or facilities is

explained in this booklet in Chapter 3.

Out-of-Pocket Costs – See the definition for “cost-sharing” above. A member’s cost-sharing

requirement to pay for a portion of services or drugs received is also referred to as the member’s

“out-of-pocket” cost requirement.

Part C – see “Medicare Advantage (MA) Plan.”

Part D – The voluntary Medicare Prescription Drug Benefit Program. (For ease of reference, we

will refer to the prescription drug benefit program as Part D.)

Part D Drugs – Drugs that can be covered under Part D. We may or may not offer all Part D

drugs. (See your formulary for a specific list of covered drugs.) Certain categories of drugs were

specifically excluded by Congress from being covered as Part D drugs.

Part D Late Enrollment Penalty – An amount added to your monthly premium for Medicare

drug coverage if you go without creditable coverage (coverage that is expected to pay, on

average, at least as much as standard Medicare prescription drug coverage) for a continuous

period of 63 days or more. You pay this higher amount as long as you have a Medicare drug

plan. There are some exceptions. For example, if you receive “Extra Help” from Medicare to pay your prescription drug plan costs, you will not pay a late enrollment penalty.



If you ever lose your low income subsidy ("Extra Help"), you would be subject to the monthly

Part D late enrollment penalty if you have ever gone without creditable prescription drug

coverage for 63 days or more.

Preferred Provider Organization (PPO) Plan – A Preferred Provider Organization plan is a

Medicare Advantage Plan that has a network of contracted providers that have agreed to treat

plan members for a specified payment amount. A PPO plan must cover all plan benefits whether

they are received from network or out-of-network providers. Member cost-sharing will generally

be higher when plan benefits are received from out-of-network providers. PPO plans have an

annual limit on your out-of-pocket costs for services received from network (preferred) providers

and a higher limit on your total combined out-of-pocket costs for services from both network

(preferred) and out-of-network (non-preferred) providers.

Premium – The periodic payment to Medicare, an insurance company, or a health care plan for

health or prescription drug coverage.

Primary Care Provider (PCP) – Your primary care provider is the doctor or other provider you

see first for most health problems. He or she makes sure you get the care you need to keep you

healthy. He or she also may talk with other doctors and health care providers about your care and

refer you to them. In many Medicare health plans, you must see your primary care provider

before you see any other health care provider. See Chapter 3, Section 2.1 for information about

Primary Care Providers.

Prior Authorization – Approval in advance to get services or certain drugs that may or may not

be on our formulary. Some in-network medical services are covered only if your doctor or other

network provider gets “prior authorization” from our plan. Covered services that need prior authorization are marked in the Benefits Chart in Chapter 4. Some drugs are covered only if your

doctor or other network provider gets “prior authorization” from us. Covered drugs that need

prior authorization are marked in the formulary.

Prosthetics and Orthotics – These are medical devices ordered by your doctor or other health

care provider. Covered items include, but are not limited to, arm, back, and neck braces; artificial

limbs; artificial eyes; and devices needed to replace an internal body part or function, including

ostomy supplies and enteral and parenteral nutrition therapy.

Quality Improvement Organization (QIO) – A group of practicing doctors and other health

care experts paid by the Federal government to check and improve the care given to Medicare

patients. See Chapter 2, Section 4 for information about how to contact the QIO for your state.

Quantity Limits – A management tool that is designed to limit the use of selected drugs for

quality, safety, or utilization reasons. Limits may be on the amount of the drug that we cover per

prescription or for a defined period of time.

Rehabilitation Services – These services include physical therapy, speech and language

therapy, and occupational therapy.



Service Area – A geographic area where a health plan accepts members if it limits membership

based on where people live. For plans that limit which doctors and hospitals you may use, it’s

also generally the area where you can get routine (non-emergency) services. The plan may

disenroll you if you permanently move out of the plan’s service area.

Skilled Nursing Facility (SNF) Care – Skilled nursing care and rehabilitation services provided

on a continuous, daily basis, in a skilled nursing facility. Examples of skilled nursing facility care

include physical therapy or intravenous injections that can only be given by a registered nurse or

doctor.

Special Needs Plan – A special type of Medicare Advantage Plan that provides more focused

health care for specific groups of people, such as those who have both Medicare and Medicaid,

who reside in a nursing home, or who have certain chronic medical conditions.

Step Therapy – A utilization tool that requires you to first try another drug to treat your medical

condition before we will cover the drug your physician may have initially prescribed.

Supplemental Security Income (SSI) – A monthly benefit paid by Social Security to people

with limited income and resources who are disabled, blind, or age 65 and older. SSI benefits are

not the same as Social Security benefits.

Urgently Needed Services – Urgently needed services are provided to treat a non-emergency,

unforeseen medical illness, injury, or condition that requires immediate medical care. Urgently

needed services may be furnished by network providers or by out-of-network providers when

network providers are temporarily unavailable or inaccessible.

MetroPlus Advantage Plan (HMO SNP) Member Services

Method Member Services – Contact Information

CALL 1-866-986-0356


24 hours a day, 7 days a week Member Services also has free language

interpreter services available for non-English speakers.

TTY 711





FAX 212-908-5196



New York, NY 10038



Health Insurance Information Counseling and Assistance Program (HIICAP) (New York’s SHIP)

HIICAP is a state program that gets money from the Federal government to give free local health

insurance counseling to people with Medicare.

Method Contact Information

CALL 1-800-701-0501

WRITE New York City Department of the Aging

2 Lafayette Street, 16th Floor

New York, NY 10007-1392

WEBSITE www.aging.ny.gov/healthbenefits

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